Presented by : Muhammad Yunus C11109399 Supervisor : Prof.Dr.dr.Ali Aspar, M, Sp.PD, Sp.JP, FIHA, FAsCC, FINASIM, FICA Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University Makassar 2014
PATIENT’S IDENTITY
Name : Mrs. K Gender : Female Age : 45 years old RM : 624731 Date of ission : August 12nd, 14
History Taking Chief Complaint : Chest pain Guided Anamnesis: Symptoms felt since 3 hours before itted to hospital. Symptoms was triggered by activity, it was felt like heavy pressed at epigastric area and it radiates to the left arm. The duration was >20 min. it wasn’t relieved by consuming ISDN 5mg/SL and rest. It usually accompanied by cold sweating. History of chest pain before (+) about 1 year ago and in hospitalized. History in angiography and advised to coronary stent. Regular medical treatment history (+).
SoB (-), history of SoB before(-), DoE (-), PND (-), orthopnea (-) History of HT (+), DM (-) Cigarette Smooking (-) Urination and defecation remains normal
Past Illness History
History of hypertension (+) History of dyslipidemia (-) History of DM is denied History of smoking (-) Family history of cardiovascular disease (-) History of chest pain (+), 1 year ago, relieved with rest and consuming ISDN 5mg/SL .
Modifiable Hypertension
Non modifiable Female 45 years old History of chest pain 1year ago
Clinical Examination GENERAL STATE Moderate illness/well-nourished/conscious VITAL SIGN - Blood pressure : 130/80 mmHg - Pulse : 108 beats/min - Breathing : 20 times/min -
Temperature : 36,6 degree celcius (Axilla)
Head Examination Eyes : anemia -/-, icterus -/-, oedema palpebra -/
Lip : cyanosis (-) Neck: JVP R+2 cmH2O (30 degree)
Chest Examination Inspection : symmetric R=L, normochest Palpation : mass (-), tenderness (-), fremitus right = left Percussion : sonor left and right Auscultation : breath sound : vesicular additional sound : ronchi -/-
vocal
wheezing -/-
Cardiac Examination Inspection : IC is not visible Palpation : IC is not palpable Percussion : Right heart border in left parasternal line, left heart border in left midclavicular line Auscultation : Regular S1/S2 heart sound, murmur (-)
Abdominal Examination Inspection : Flat and follows
breath
movement Auscultation : Peristaltic sound (+) Palpation : Liver and spleen not palpable Percussion : Timpany (+)
Extremities - Oedema : Pretibial -/-
Dorsum pedis -/-
Rhythm : sinus rhytm QRS rate : HR 107 bpm P wave : 0.08 sec PR interval : 0.16 sec QRS complex : 0.08 sec Axis : Normoaxis ST segment : isoelektric Conclusion: Sinus Tachycardi, normoaxis
TEST
RESULT
NORMAL VALUE
WBC
7,7 x 103 /uL
4,0-10,0 x 103 /l
RBC
4,8 x 106 /Ul
4,0-6,0 x 106 /l
Hb
14,1mg/dl
13,0-17,0 g/dl
Hct
40,1 %
40,0-54,0 %
GDS
105 mg/dl
140 mg/dl
Ureum
31 mg/dl
10-50 mg/dl
Creatinin
0,5 mg/dl
M(<1,3);F(<1,1) mg/dl
PLT
321 x 103 /uL
150-500 x 103 /l
TEST
RESULT
NORMAL VALUE
CK
90 U/L
L(<190) P (<167)
Troponin T
0.01
0.05
SGOT
32 mg/dl
<38 U/l
SGPT
53 mg/dl
<41 U/l
Total Cholesterol
342 mg/dl
200 mg/dl
HDL
51 mg/dl
M(>55);F(>65) mg/dl
LDL
157 mg/dl
<130 mg/dl
TG
267 mg/dl
200 mg/dl
Uric Acid
4.3 mg/dl
2,4-5,7 mg/dl
CHEST X-RAY PA
Unstable Angina Pectoris
Bed rest O2 2-4 LPM via Nasal Canule IVFD NaCl 0,9% 12 dpm Nitrate : ISDN Fasorbid (10mg/cc) 2mg/hr/SP Anti-platelet aggregation :
Aspilet 80 mg 1x2 Clopidogrel 75 mg 1x4 Anti-coagulant : Fondaparinux 2,5mg/24hrs/SC Anti-Hypertension : Captopril 25mg 1-1-1 Statin : Simvastatin 20mg (0-0-1) Anti-anxiety : Alprazolam 0.5 mg (0-0-1) Laxative: Laxadyne syr 0-0-2
Acute Coronary Syndrome – Unstable Angina Pectoris
Spectrum of disease related to myocardial ischemia
Plaque Fissure or Rupture
Platelet Adhesion Platelet Activation Platelet Aggregation Thrombotic Occlusion
Imbala nce
Non-modifiable Non-modifiable Age Age Gender Gender Family History of Hearth Disease Family History of Hearth Disease
Modifiable Modifiable Smoking •Dislipidemia Smoking •Dislipidemia Hypertension •Hypertension Diabetes mellitus •Diabetes mellitus Lack of exercise •Lack of exercise Obesity •Obesity
Prolonged pain (usually >20 mins) – constricting, crushing, squeezing
Usually retrosternal location, radiating to left chest, left arm, can be epigastric
Dyspnea
Diaphoresis
Palpitations
Nausea/vomiting
Occurring at rest (or with minimal exertion) and usually lasting more than 20 minutes (if not interrupted by nitroglycerin) Being severe and described as frank pain and of new onset (i.e., within 1 month) Occurring with a crescendo pattern (i.e., more severe, prolonged, or frequent than previously
DIAGNOSIS ECG Yes
No
Lab Yes
No
Unstable Angina Therapeutic Goals
33