CASE REPORT CARDIOLOGY DEPARTMENT

Presented by: Amelya Matasik C11108175 Supervisor: dr. Pendrik Tandean, Sp. PD-KKV, FINASIM
DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK BAGIAN KARDIOLOGI FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN MAKASSAR 2013

NAME AGE GENDER MR Day of Admission

: Mr. M : 62 years old : Male : 629171 : 27/9/2013

Chief Complain : Chest Pain Structural Anamnesis: Occurred since about 7 hours before admitted to the hospital. On the left side the chest pain feels dull heavy pain, it seems to radiates to the back. It does not radiate to the shoulder/arm. Chest pain last for 30 minutes. The pain is not lessen at rest or with medication. Patient had experienced chest pain for a year long.However, patient did not check it to the hospital, because at that time the pain it did not disturb his everyday activities and lessen at rest. The chest pain accompanied with shortness of breath, cold sweat (+), fever (-), cough (-), nausea (+), vomit (+), epigastric pain (-). Defecation and urination normal.

History of cigarette smoking (-) History of alcohol consumption(-) History of hypertension (+) , since 3 years ago with uncontrolled therapy. History of Amlodipin consumption 5 mg 1x1 History of Diabetes mellitus (-) History of heart disease is denied

General status:

Moderate Ilness/ Overweight/Conscious Body Weight :70 kg Body Height :170 cm Body Mass Index : 24,2 kg/m2 Blood Pressure Heart Rate Respiratory Rate Body Temperature : 150/100 mmHg : 88 bpm : 20 : 36,7 C

Vital Status

Head and Neck Examinations: Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-) Lip : Cyanosis (-) Neck : JVP R +2 cmHO Chest Examination Inspection Palpation Percussion

: Symmetric between left and right chest. : No mass, no tenderness. : Sonor between left and right chest, lungliver border in ICS IV right anterior . Auscultation : Breath Sounds : Vesicular Adventitious breath sound : Ronchi -/-, wheezing -/-

Cardiac Examination Inspection : Heart apex was not visible Palpation : Heart apex was not palpable Percussion : Dull, left heart border left midclavicular line ICS V. Auscultation : Heart Sounds : S I/II regular, murmur (-) gallop(-)

Abdominal Examination Inspection : Flat, following breath movement Auscultation : Peristaltic sound (+), normal Palpation : No mass, no tenderness, no palpable liver or spleen. Percussion : Tympani (+)
Extremities Examination Pretibial edema -/ Dorsal pedis edema -/-

ECG :Sinus rhythm, QRS rate 83 bites/ minute, north west axis, PR interval 0,16 s, P wave 0,08 s, QRS complex 0,08 s, Q patologis III, aVF, V1-V3 ST segment elevation V1-V5 Conclusion : sinus rhythm, HR 83 bite/minute, whole anterior acute myocard infraction , old myocard infraction inferior

ECG :Sinus rhythm, QRS rate 93 bites/ minute, right axis devilation, PR interval 0,12 s, P wave 0,08 s, QRS comlex 0,08 s, Q patologis in III, aVF, V1-V3 ST segment elevation in V1-V5 Conclusion : sinus rhythm, HR 93 bite/minute, whole anterior acute myocard infraction , old myocard infraction inferior

Complete blood count

Test WBC RBC HGB HCT PLT Result 9,05 x 103/ul 4.86 x 106/l 15.0 gr/dl 44,6 % 141 x 103 /l Normal value 4.0 10.0 x 103 4.0 6.0 x 106 12 16 37 48 150 400 x 103

Blood Chemistry
Test GDS Ureum Creatinine SGOT SGPT Total Chol HDL Chol LDL Chol Result 141 mg/dl 33mg/dl 0,9 mgr/dl 24u/l 21 u/l 123 mg/dl 23mg/dl 99 mg/dl Normal value <140 10 50 < 1.3 <38 <41 <200 > 55 < 130

Cardiac Enzymes
Test CK CK-MB Troponin-T Result 211U/L 10 U/L <0.02 Normal value <190 <25 <0,05

Electrolyte
Test Result Normal value

Na
K Cl

145 mmol/l
3.5 mmol/l 110 mmol/l

136-145
3.5-5.1 97-111

Cloudy parahilar accompanied with cardiovascular suprahilar dilatation on both lungs There is no specific active process seen on both lungs Cor CTI widen 0,57 cm, aorta dilated and calcified Both sinuses and diaphragma in good condition Bones intact

Impression: Cardiomegaly with signs of Pulmonary edema dilatation et atherosclerosis aorta

1. ST elevation myocardial infarction (STEMI) whole anterior onset >6 hours KILLIP I, 2. Old myocard infraction inferior 3. Grade I hypertension

O2 2 -4 Lpm IVFD NaCl 0,9% 10 drops/min Aspilet 80 mg 0-1-0 Aspirin (Antiplatelet) Plavix 75 mg 0-0-1 Clopidogrel (Antiplatelet) Injection ISDN 0,5 mg/hours/SP Nitrat Captopril 25 mg 1-1-1 ACE-Inhibitor

Simvastatin 20 mg 0-0-1 Statin (Anticholesterol) Alprazolam 0,5 mg 0-0-1 Antianxietas Laxadyn syr 0-0-2c

Echocardiography

ST ELEVATION MYOCARDIAL INFARCTION

Myocardial infarction (MI) rapid development of myocardial necrosis caused by a critical imbalance between the oxygen supply and demand of the myocardium. This usually results from plaque rupture with thrombus formation in a coronary vessels, resulting in an acute reduction of blood supply to a portion of the myocardium.

 Occurs when coronary

blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates.

NON- MODIFIABLE

MODIFIABLE
Smoking Hypertension Diabetis Mellitus

Gender and Age

Men, increased risk after age 45 Women, increased risk after age 55

Family History

Heart disease diagnosed before age 55 in father or brother

Dyslipidemia
Obesity Lack of physical activity

Heart disease diagnosed before

age 65 in mother or sister

Substernal chest pain / chest discomfort radiated to the left arm, shoulder, neck, jaw. Penetrated to the back. The chest discomfort may also be described as a dull pain ,pressure, squeezing or crushing sensation or burning sensation Duration more than 20 minutes. more intense and persistent. Not fully relieved by rest or nitroglycerine Often accompanied by systemic symptoms: nausea, vomiting, shortness of breath, palpitation, fatigue, cold sweat, light headedness

1.
2.

3.

Clinical history of ischemic type chest pain lasting >20 minutes Changes in serial ECG tracings Rise and fall of serum cardiac biomarkers such as creatinine kinase-MB fraction and troponin

ST segment elevation over area of damage ST depression in leads opposite infarction Pathological Q waves Reduced R waves Inverted T waves

Cardiac enzyme biomarker

CK CK-MB Troponin T and I

Signs of myocardial ischemia ECG

Yes

ST segmen elevation ?
No

Acute Myocardial Infarction (STEMI) Yes NSTEMI ( Non ST-Elevation Myocardial Infarction )

Lab

Biochemical cardiac markers ?

No

Unstable Angina

Managing chest pain and anxiety o Bed rest o Diet o O2 2-4 lpm o Nitrate sublingual/oral/IV o Antiplatelet: aspirin and clopidogrel o Morphine/ pethidine Stabilizing hemodynamic (blood pressure and peripheral pulse control) o -blocker o Calcium channel blocker (CCB) o ACE-Inhibitor Reperfusion of the myocardium o Thrombolytic

Pericarditis Arrhythmia Acute mitral regurgitation Ventricular septal rupture Cardiogenic shock

Risk Factor Age > 65 years old Age > 75 years old History of angina/hypertension/DM Systolic BP <100

Score 2 3 1/1/1 3

Heart rate > 100

Killip II-IV Weight > 67kg Anterior MI or LBBB Delay treatment >4hours

2
2 1 1 1

Total Score 0 1 2 3 4 5 6 7 8 9-16

Risk of Death in 30 days 0.8% 1.6% 2.2% 4.4% 7.3% 12.4% 16.1% 23.4% 26.8% 35.9%

Class I II

III IV

Description no clinical signs of heart failure rales or crackles in the lungs, an S3, and elevated jugular venous pressure acute pulmonary edema cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction

Mortality Rate (%)

6

17

30 - 40 60 80

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