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OLEH Icha Marissa Sofyan C11108318

Supervisor : dr. Khalid Saleh, SpPD-KKV.FINASIM

PATIENT IDENTITY
Name : Mr. S Age : 75 years old Gender : Male Medical record : 005286 Date of admission : 7rd November 2012

HISTORY TAKING
Chief complaint:

Chest pain Guided 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 (-)

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 STATE

Moderate 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 cmH2O Chest 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 wasnt 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 murmur (-)

: Regular of I/II heart sound,

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 rhythm QRS rate: HR 69 bpm P wave : 0.06 sec PR interval: 0.12 sec QRS complex: 0.08 sec Axis: Normo axis ST segment: isoelectric T-wave inverted: I, AvL, V5, V6 Conclusion: sinus rhythm Hr= 69 bpm, lateral wall miocard ischemia

CHEST X-RAY AP

Conclusion Aspek bronchitis Dilatatio aorta

Test BLOOD TEST WBC RBC HGB HCT PLT GDS

Result

LABORATORIUM FINDING
Test Result CHEMICAL BLOOD TEST Ureum Creatinine SGOT SGPT Trigliserida HDL LDL Choles. Tot. ELEKTROLIT Natrium Kalium klorida 118 mmol 5,5 mmol 92 mmol 38 mg/L 1,9mg/L 21 U/L 40 U/L 58 48 75 171

19,16x103 /uL 4,19x106/uL 12,8 g/dL 37,5% 248x103/uL 169 mg/dL

CARDIAC BIOMARKER CK CK-MB Troponin-T 81 u/L 19 u/L Negative

WORKING DIAGNOSIS

UNSTABLE ANGINA PECTORIS HT grade I on treatment

THERAPY
O2 via nasal kanul 2-4 liters/minute IVFD NaCl 0,9 % 10 tpm Bed Rest Antiplatelet:

- 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 0-0-1 Antianxiety agents: Alprazolam 0.5mg 0-0-1 Laxans : Laxadyn Syrup 0-0-2 C ISDN: Cedocard 5 mg/SP antikoagulan : Arixtra 2,5 mg/hari/SC Antihipertensi : Farmoten 12,5 1-0-0

DISCUSSION
CAD
STABLE ANGINA PECTORIS

ACS

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.

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

RISK FACTOR

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

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

PATHOGENESIS
Plaque rupture Thrombus formation Incomplete/ 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

Diagnose
Signs of myocardial ischemia ECG ST segmen elevation ? Lab Biochemical cardiac markers ?

Yes

Acute Myocardial Infarction ( Q-wave, non-Q wave ) NSTEMI ( No ST-Segment Elevation Myocardial Infarction )

Yes

Unstable Angina

MANAGEMENT
Therapeutic Goals
Reduce myocardial ischemia Control of symptoms Prevention of MI and death

MANAGEMENT

http://www.cardiosmart.org/HeartDisea