PATIENT IDENTITY
Medical Record
Name
Gender
Age
Address
Date of admission
: 622386
: Mr. IH
: Male
: 43 years old
: Sudiang
: August 18th 2013
HISTORY TAKING
Chief complaint:
Chest Pain
History of Present Illness:
The chest pain began since 4 days before he was admitted to Wahidin
Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the
patient was playing video game. The pain is described like dull heavy feeling on the
left part of the chest, not spreading . The chest pain felt continuously more than 20
minutes duration, and not relieved by rest. The chest pain was accompanied with cold
sweat and feeling nauseated. Theres no history of any chest pain before. Theres also
no history of fever, high blood pressure, and diabetes. History of any heart disease in
the family denied. Patient been smoking for almost 20 years with 12 cigarette each
days .
Patient has history of epigastric pain. Urination and defecation were normal.
HISTORY TAKING
History of Past Illness:
No history of dyslipidemia
No history of asthma
RISK FACTOR
Non
Modifiable
Gender: Male
Age: 43 yo
Modifiable
Smoking (+)
PHYSICAL EXAMINATION
General Status
PHYSICAL EXAMINATION
Head Examination
Eyes
: Anemic -/-, Icterus -/ Lips
: Cyanosis (-)
Neck
: Lymphadenopathy (-), JVP R+0 cmH2O
Thorax Examination
Insp.
: Symmetrical R=L , normochest
Palp.
: Mass (-), tenderness (-), Vocal Fremitus R=L
Perc.
: Sonor
Ausc.
: Vesicular
Ronchi -/-,
Wheezing -/-
PHYSICAL EXAMINATION
Cardiac Examination
PHYSICAL EXAMINATION
Abdominal Examination
Insp.
: Flat and following breath movement
Ausc.
: Peristaltic sound (+), normal
Palp.
: Liver and spleen is unpalpable
Perc.
: Tympani (+), ascites (-)
Extremities
Oedema : Pretibial -/-, Dorsum pedis -/-
ELECTROCARDIOGRAPHY
ELECTROCARDIOGRAPHY
Interpretation:
Rhythm
P-Rate
QRS-Rate
P-Wave
PR-Interval
QRS Complex
Axis
ST-Segment
T-Wave
: Sinus ritme
: x/m
: HR 68 bpm, reguler
: 0.12 sec
: 0.20 sec
: 0.08 sec
: Normal axis 50
: ST-elevation on lead I and AvL
ST-elevation on lead V2, V3, V4 , V5,V6
: Normal
LABORATORY EXAMINATION
WBC
HB
PLT
HCT
GDS
Ureum
Creatinin
Bil. Tot
Bil. Direct
: 17.71
: 14,1 gr/dl
: 300.000
: 38,1 %
: 131 mg/dl
: 19 mg/dl
: 1,1 mg/d
: 0,48 mg/dl
: 0,14 mg/dl
CK
CKMB
Trop. T
Na
K
Cl
SGOT
SGPT
Albumin
PT
APTT
: 5581 U/L
: 457 U/L
: >2.0
: 145 mmol/l
: 4,5 mmol/l
: 109 mmol/l
: 17 U/L
: 22 U/L
: 4,0 gr/dl
: 9.9
: 23.9
DIAGNOSIS
- STEMI Extensive Anterior with 4 hour onset
Killip I
INITIAL MANAGEMENT
Bed rest
O2 2-4 LPM (via nasal canule)
Heart Diet
IVFD NaCl 0,9% loading 500 cc/24 hours
Thrombolytic
Streptokinase (Streptase) 1.5 million IU in 100ml D5% within 1 hours
Anti Platelet Aggregation
ASA (Aspilet) loading dose 80 mg (2 x 80 mg) maintenance 1-0-0
Clopidogrel (Plavix) loading dose 75 mg (4 x 75 mg) maintenance 0-1-0
Anti cholesterol
HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) 0-0-1
Anti coagulant
PLANNING
Echocardiography
Coronary angiography
Retrosternal
or substernal
chest pain
1
point
Increased by
activity or
emotion
1
point
Relieved by
resting or
nitrate SL
DEFINITION
Acute Coronary Syndrome (ACS) is a term for
situations where the blood supplied to the heart
CLASSIFICATION
PATHOPHYSIOLOGY
Vulnerable Plaque
Thrombosis
Vasospasme
Plaque disruption and
thrombosis that result in
complete coronary artery
occlusion leads to
transmural ischemia and
necrosis, the hallmark of
ST-segment elevation
myocardial infarction
(STEMI)
PATHOGENESIS
Lipid transport disorder
Inflamation
Plaque deposition
Erosion
Stable plaque
Plaque rupture
Thrombus
Thrombosis
RISK FACTOR
Non- Modifiable
Modifiable
Smoking
Hypertension
55
Family History
Heart disease diagnosed before
Diabetes Mellitus
Dyslipidemia
Obesity
Lack of physical activity
DIAGNOSIS OF ACS
At least 2 of the following:
1. Ischemic symptoms
1. ISCHEMIC SYMPTOMS
Prolonged pain (usually >20
minutes) constricting, crushing,
squeezing
Dyspnea
Diaphoresis
Palpitations
Nausea/vomiting
2. DIAGNOSTIC ECG
CHANGES
ECG CHANGES
Timing of myocardial infarction based on ECG
CK-MB
CK
SGOT
LDH
Myoglobin
CARDIAC BIOMARKER
DIAGNOSIS
INITIAL MANAGEMENT
PROGNOSIS
KILLIP CLASSIFICATION
Class
Description
II
17
III
30 - 40
IV
60 80