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PATIENTS IDENTITY
Name : Mr. A Age : 52 years old Register no. : 47 82 46 Date of admission : September 4th, 2011 Time of admission : 11.00 a.m.
HISTORY TAKING
Chief complaint : Chest pain
It had been felt since two days ago, suddenly and
uncontinuously. It had been worsen since a day before he was admitted to the hospital (at 08.30 p.m., September 3rd, 2011). The chest pain was felt more frequent, sometimes he felt like strangulated. He had sweat during the chest pain. There were no dyspnea, nausea, and vomiting.
Risk Factors
MODIFIABLE : Smoking (+) Hypertension (-) Diabetes mellitus (-) Dyslipidemia (-) Obesity (-)
NON-MODIFIABLE Gender : man Age : 52 years old Personal history of CAD (-) Family history of CAD (-)
PHYSICAL EXAMINATION
General Status :
moderate-illness/well-nourished/composmentis
Vital Sign :
BP = 130/90 mmHg
Pulse = 85 bpm, regular RR = 22 bpm Temperature = afebris
Regional Status
Head Examination Eyes : anemic -/-, icterus -/ Lip : cyanosis (-) Neck : lymphadenopathy (-), JVP R-1 cmH2O supine Chest Examination Inspection : symmetric R=L, normochest Palpation : mass (-), tenderness (-), VF R=L Percussion : sonor Auscultation : vesicular breath sound, no additional sound
Regional Status
Cardiac Examination Inspection : IC wasnt visible Palpation : IC wasnt palpable Percussion : normal heart size
Upper border : left 2nd ICS Lower border : left 5th ICS Right border : right parasternalis line Left border : left medioclavicular line
Regional Status
Abdominal Examination Inspection : convex and following breath movement Auscultation : peristaltic sound (+) , normal Palpation : liver and spleen unpalpable Percussion : tympani, ascites (-) Extremities Oedema : pretibial -/- ; dorsum pedis -/ Cold extremities (-)
ELECTROCARDIOGRAPHY
(4th September 2011 at emergency unit)
Interpretation
Sinus Rhythm, heart rate 76 bpm
Normal T wave
LABORATORY FINDINGS
Haematological Routine Examination WBC = 12,50. 103 RBC = 4,94. 106 HGB = 16,1 HCT = 46,3 PLT = 290. 103 Chemical Blood Examination and Cardiac enzymes GDS = 108 GOT/GPT = 31/37 CK = 222 CKMB = no reagen Trop-T = 0,13
WORKING DIAGNOSE
ST Elevation Myocardial Infarction extensive
MANAGEMENT
O2 4-6 L/minute
continued once daily on the next day Clopidogrel (Plavix) 300 mg (loading dose), then continued once daily on the next day
MANAGEMENT
Nitrat (Farsorbid) 5 mg (SL), then continued with
Farsorbid via SP Na Fondaparinux (Arixtra) 2,5 mg/24 hours/SC Simvastatin 20 mg 0-0-1 Bisoprolol 2,5 mg once daily Captopril 6,25 mg three times daily Laxadyn syr. once daily Alprazolam 0,5 mg 0-0-1 The patient must be catheterized
PLANNING
Enter the patient to CVCU
Coronary Angiography
ECHOCARDIOGRAPHY
Interpretation
Conclusion:
Systolic
and dyastolic dysfunction of left ventricle e.c. Coronary Artery Disease Left Ventricle Hypertrophy EF 36%
References: 1. Kabo P. Penyakit jantung koroner. Dalam: Bagaimana menggunakan obat-obat kardiovaskular secara rasional. Jakarta: Balai Penerbit FKUI; 2010. 2. Fauci et al. ST-segment elevation myocardial infarction. In: Harrisons Principles of Internal Medicine 17th edition. New York: The McGraw-Hill Companies; 2008. Chapter 239. 3. Brashers VL. Ischemic Heart Disease. In: Clinical application of pathophysiology 3rd ed : An evidence-based approach. United State of America: Elsevier Inc; 2002. p. 38.
INTRODUCTION
irreversible necrosis of heart muscle due to prolonged ischemia, which is suddenly happened.1 Acute myocardial infarction (AMI) is one of the most common diagnoses in hospitalized patients in industrialized countries.2
Acute myocardial infarction (AMI) is an
PATHOPHYSIOLOGY
STEMI
generally occurs when coronary blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis.1 In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when condition favor thrombogenesis.2
RISK FACTORS
Modifiable: Hypertension Diabetes Mellitus Dyslipidemia Smoking Obesity Non-modifiable: Gender: male Age >45 years old Personal history of Coronary Artery Disease Family history of Coronary Artery Disease
CLINICAL FEATURES
Deep and visceral chest pain > 20 minutes, similar to
discomfort of angina pectoris but commonly occurs at rest, more severe, and lasts longer.2 Feels like heavy, squeezing, crushing, burning sensation.2 Involves the central portion of chest and/or the epigastrium, radiates to the arm, abdomen, back, lower jaw, and neck.2 It is often accompanied by weakness, sweating, nausea, vomiting, anxiety.2 Not relieved by rest or nitrat.1
HOW TO DIAGNOSE
Signs of myocardial ischemia ECG ST segment elevation?
No Yes Acute Myocardial Infarction
Lab
Yes
NSTEMI ( Non ST-Elevation Myocardial Infarction )
Unstable Angina
Diagram 1. Flowchart to diagnose acute coronary syndrome (from 3rd reference)
MANAGEMENT
Fixing the chest pain and fearness1 o Bed rest o Diet o O2 2-4 lpm via nasal prongs or face mask o Sublingual/oral/IV nitroglycerine o Antiplatelet: aspirin and clopidogrel o Morfin/petidine o Diazepam 2-5mg/8 hour Stabilizing the hemodynamic (blood pressure and peripheral pulse
control)1 o -blocker o Calcium channel blocker (CCB) o ACE-Inhibitor Reperfusion of the myocard1 o Thrombolytic
KILLIP CLASSIFICATION
Class I II 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
III IV
30 - 40 60 80