OLEHOLEH

Icha Marissa SofyanIcha Marissa Sofyan

C11108318C11108318

SupervisorSupervisor ::

dr. Khalid Saleh, SpPD-KKV.FINASIMdr. Khalid Saleh, SpPD-KKV.FINASIM

PATIENT IDENTITY

Name : Mr. SAge : 75 years oldGender : MaleMedical record: 005286Date of admission : 7rd November 2012

HISTORY TAKINGChief complaint: Chest painGuided anamnesis:

Occurred 1 week before admission, getting worse 2 days ago. The patient complain of pain on the left side of chest, like pressed by a heavy thing, radiate to back side. Frequency of recurrent attack 4 times a day with increasing intensity, duration more than 30 minutes. The pain triggered by activity and not relieved by resting. Nausea(+) vomiting (+) PND (-) DOE (-) orthopneu (-).Defecation and urination were normal.

Past Illness History: - History of hypertension since 2 years ago,

control regularly. - History of coronary artery disease 1 year

ago- Smoking (-)- Family history of heart disease (-)- History of dyslipidemia (-)- History of DM (-)

CLINICAL EXAMINATION

GENERAL STATEModerate illness/normoweight/conscious

VITAL SIGN- Blood pressure : 140/70 mmHg- Pulse : 88 bpm- Breathing : 22 x/i- Temperature: 36.50C

Head Examination• Eyes : anemic -/-, icterus -/-• Lip : cyanosis (-)• Neck: lymphadenopathy (-), JVP R+2 cmH2OChest Examination• Inspection : symmetric R=L, normochest• Palpation : mass (-), tenderness (-), VF

R=L• Percussion : sonor• Auscultation : breath sound :vesicular

additional sound : ronchi-/-,wheezing -/-

Cardiac Examination• Inspection : IC wasn’t visible• Palpation : IC palpable • Percussion : normal heart size

-Upper border : left 2nd ICS-Lower border : left 5th ICS -Right border : right parasternalis line-Left border : 1st finger of left medioclavicular line

• Auscultation : Regular of I/II heart sound, murmur (-)

Abdominal Examination - Inspection: flat and following breath

movement- Auscultation: peristaltic sound (+) ,

normal- Palpation : liver and spleen

unpalpable- Percussion : tympani, ascites (-)

Extremities - Oedema : pretibial -/-

dorsum pedis -/-

ELECTROCARDIOGRAM

Interpretation :Rhythm: sinus rhythmQRS rate: HR 69 bpmP wave : 0.06 secPR interval: 0.12 secQRS complex: 0.08 secAxis: Normo axisST segment: isoelectricT-wave inverted: I, AvL, V5, V6

Conclusion: sinus rhythm Hr= 69 bpm, lateral wall miocard ischemia

CHEST X-RAY APConclusionAspek bronchitisDilatatio aorta

LABORATORIUM FINDING

Test Result Test Result

BLOOD TEST CHEMICAL BLOOD TEST

WBC 19,16x103 /uL Ureum 38 mg/L

RBC 4,19x106/uL Creatinine 1,9mg/L

HGB 12,8 g/dL SGOT 21 U/L

HCT 37,5% SGPT 40 U/L

PLT 248x103/uL Trigliserida 58

HDL 48

GDS 169 mg/dL LDL 75

Choles. Tot. 171

CARDIAC BIOMARKER ELEKTROLIT

CK 81 u/L Natrium 118 mmol

CK-MB 19 u/L Kalium 5,5 mmol

Troponin-T Negative klorida 92 mmol

WORKING DIAGNOSIS

• UNSTABLE ANGINA PECTORIS• HT grade I on treatment

THERAPYO2 via nasal kanul 2-4 liters/minuteIVFD NaCl 0,9 % 10 tpmBed RestAntiplatelet:

- Aspilet, 80 mg, 2 tab (loading dose) next 0-1-0 - Clopidogrel, 75mg, 4 tab (loading dose) next 1-0-0

Anticholesterol : Simvastatin 20 mg 0-0-1Antianxiety agents: Alprazolam 0.5mg 0-0-1Laxans : Laxadyn Syrup 0-0-2 CISDN: Cedocard 5 mg/SP antikoagulan : Arixtra 2,5 mg/hari/SCAntihipertensi : Farmoten 12,5 1-0-0

DISCUSSIONCAD

STABLE ANGINA

PECTORISACS

UAP NSTEMI STEMI

DEFENITION

Angina pectoris :a syndrome characterized by chest

pain resulting from an imbalance between O2 supply & demand

most commonly caused by the inability of atherosclerotic coronary arteries to perfuse the heart under conditions of increased myocardial O2 consumption.

CLASSIFICATIONCANADIAN CARDIOVASCULAR SOCIETY FUNCTIONAL CLASSIFICATIONCLASS I : No angina with ordinary activity. Angina with sternuous, rapid or prolonged exertionCLASS II: Slight limitation of ordinary activity; angina when walking up stairs briskly, or walking on a cold or windy dayCLASS III: Marked limitation; angina when walking at normal pace up flight of stairs, or walking 1-2 blocks distanceCLASS IV: Angina on minimal exertion or at rest

RISK FACTOR

Modifiable :- Smoking- Dyslipidemia - Raised Blood pressure- Diabetes melitus- Obesity

Modifiable :- Smoking- Dyslipidemia - Raised Blood pressure- Diabetes melitus- Obesity

Non-Modifiable :- Personal History of CVD- Family History of CVD- Age- Gender

Non-Modifiable :- Personal History of CVD- Family History of CVD- Age- Gender

PATHOGENESIS

Plaque ruptureThrombus formationIncomplete/ intermittent

occlusion of the infact-related vessel to the presence of collateral channels/ to small size of affected vessel.

DIAGNOSE

Cardiology, Desmond G. Julian, J.Campbell Cowan, James M. McLenachan, 8th edition, Elsevier, 2005

Yes

Yes

Acute Myocardial Infarction

( Q-wave, non-Q wave )

NSTEMI( No ST-Segment

Elevation Myocardial Infarction )

Unstable Angina

Signs of myocardial ischemia

ST segmen elevation ?

Biochemical cardiac markers ?

ECG

Lab

DiagnoseDiagnose

MANAGEMENT

Therapeutic Goals

Reduce myocardial ischemia Control of symptoms Prevention of MI and death

MANAGEMENT

http://www.cardiosmart.org/HeartDisease