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Case Report

Medical Faculty of Hasanuddin University, Makassar 2013

Patient Identity
• • • • MR number Name Age Date administered : : : : 151821 Mr.SU 65 years old May 4th 2013

History Taking
Chief complaint: Chest pain • It was felt since 9 hours before admitted to hospital. It was felt at the middle of chest, like pressed by a heavy things and radiated to his neck and left arm. It occured suddenly with duration more than 20 minutes, didn’t trigerred by activity and didn’t relieved by rest.

• Shortness of breath (+), since 1 months ago, he can sleep with 12 pillow. DOE (+) , PND (-), Orthopnea (-)
• Cough (-) • Epigastric pain (+), Nausea (+), vomit (-), sweating (+) • Defecation: normal • Micturition: normal

Past Medical History • History of hypertension (+) since long time ago and took medicine regularly • History of diabetes mellitus (+) since 10 years ago took medicine regularly • History of dyslipidemia (-) • History of smoking (-) • History of hospitalization with stroke in 2000. 2006. and 2011 • History of chest pain before (-) • Family history (-) .

Risk Factor Modifiable : .Stroke .Diabetes mellitus Non .Hypertension .Modifiable : .Gender (male) .Age : 65 years old .

70 C .Physical Examination • General status Moderate illness/well nourished/conscious • Vital sign – BP : – HR : – RR : –T : 130/90 mmHg 80 x/min 28x/min 36.

Auscultation : Symmetric right = left.Percussion .Neck : Anemis -/-.Lip .Inspection .Eyes .Physical Examination Regional status Head Examination . lung-liver border in ICS VI right anterior : Breath sound : Bronchovesicular Additional sound : Ronchi +/+ basal. wheezing -/- .Palpation . normochest : No mass. icterus -/: Cyanosis (-) : JVP R +3 cmH2O Chest Examination . no tenderness : Sonor.

Oedema pretibial -/.Percussion : flat. liver and spleen unpalpable : tymphani.Auscultation .Inspection .Oedema dorsum pedis -/- .Inspection : Ictus cordis invisible . left heart border midclavicle line ICS V .Auscultation : Regular of I/II heart sound. ascites (-) Extremities . no murmur Abdominal . normal : No mass.Palpation . no tenderness.Percussion : Right heart border in right parasternal line.Cardiac Examination . following breath movement : Peristaltic sound (+).Palpation : Ictus cordis impalpable .

Electrocardiography (ECG) .

Interpretation: Rhythm : Sinus rhytm HR/QRS rate: 83 x/min Axis : Normal P wave: 0.08 sec PR interval: 0. III. AVF .16 sec ST segmen: ST elevasi V1-V4 T wave : T inverted pada lead II.2 sec QRS Complex: 0.

00-5. P(<167) <25 negative 150-200 .0-48.0 PLT CK CK-MB TROPONIN-T CHOL TOT 271[10^3/uL] 760 [U/L] 52 [U/L] 0.0 4.27 288 150-400 L(<190).8[%] 12.0-16.05 [10^6/uL] NORMAL 4.9 [g/dL] 37.0-10.440 [10^3/uL] 4.Laboratory Findings RESULT WBC RBC 8.0 37.00 HGB HCT 12.

9 45 1.5-5. P(<1.3).1 CHLORIDE 1109 97-111 .4 47 32 143 3.RESULT LABORATORY FINDINGS NORMAL GDS HbA1C UREUM CREATININE SGOT SGPT NATRIUM KALIUM 269 5.1) <38 <41 136-145 3.8 140 4-6 10-50 L(<1.

Thorax Photo Interpretation: In Normal Limit .

Echocardiography .

apical. EF 38% • LVH (+) • Anterior. and mid septal hipokinetic • EV function good (TAPSE 1.9) • MR Mild-Mud . apico septal.Echocardiography • Interpretation • Sistolic and diastolic LV disfunction.

Working Diagnosis STEMI Anterior Wall Onset 9 Hrs KILLIP II Hypertention Gr I DM type II .

5 mg 0 .9 % 10 drips/min • Isosorbid dinitrat : Cedocard 2mg/amp/jam • Simvastatin 20 mg 0 – 0 – 1 • Anti platelet aggregation : .Clopidogrel: Plavix 75 mg loading dose 4 tab  75 mg 1 – 0 – 0 • Anticoagulant : Arixtra 2.1 • Stool softener : Laxadyn syrup 0 .2C • Novorapid 6-6-6 • Lantus 0-0-12 .0 .Initial Management • Bed rest • Cardiac Diet • O2 3-4 ltr/min • IVFD NaCl 0.5 mg/24 h/ SC • ARB : Valsartan 80 mg 0-0-1 • Anti anxietas : Alprazolam 0.Aspirin : Aspilet 80 mg loading dose 2 tab  80 mg 0 – 1 – 0 .0 .

DISCUSSION : Acute Coronary Syndrome (ST-Elevation Myocard Infarction) .

GUIDELINES ON THE MANAGEMENT OF STABLE A NGINA PECTORIS .• Myocardial ischemia is caused by imbalance between myocardial oxygen supply and myocardial oxygen consumption. EUROPEAN HEART JOURNAL. • Myocardial infarction (MI) is the rapid development of myocardial necrosis.

III.Regions of the Myocardium Lateral I. aVF Anterior / Septal V1-V4 .V5-V6 Inferior II. AVL.

GUIDELINES ON THE MANAGEMENT OF STABLE A NGINA PECTORIS .EUROPEAN HEART JOURNAL.

Diagnosis .

ORG/WIKI/MYOCARDIAL_INFARCTION .WHO Diagnostic Criteria • • • Clinical history of ischaemic 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 HTTP://EN.W IKIPEDIA.

CARDIAC BIOMAKERS .

21 (SUPPL 2):II-4II-6. Vascular death) American Heart Association. diet. smoking. Heart and Stroke facts: 1997 Statistical supplement. Stroke 1997.RISK FACTORS FOR ATHEROTHROMBOSIS Hypercoagulable states Homocysteinemia Diabetes Obesity Genetics Life-style (e. arterioscle TrombVasc bio 1997.Laurila et al. Wolf Stroke 1990. lack of exercise) Hyperlipidemia Hypertension Gender Infection? Age Atherotrombotic Manifestations (MI. Graham et al JAMA 1997. Ischemic stroke.277: 1775-1781.101(5).g.17:2910-2913.Grau et al.Brigden Postgrad Med.26.249262 .1724-1729.

BAGAIMANA MENGGUNAKAN OBAT-OBAT KARDIOVASKULAR SECARA RASIONAL.Treatment • Relieve pain • Hemodinamic stabilitation • Miokardial reperfusion • Prevent the complication KABO P. 2010 .

2010 . BAGAIMANA MENGGUNAKAN OBAT-OBAT KARDIOVASKULAR SECARA RASIONAL.Treatment • Oxygen Surgical revascularization • PTCA (percutaneous transluminal coronary angioplasty) • Nitrate • Anti platelet agent • Anti koagulan • Morphine / pethidine • Trombolitic • ß-blocker • CABG (coronary artery bypass grafting ) • ACE inhibitors • Lipid lowering agent KABO P.

II and elevated jugular venous pressure acute pulmonary edema III cardiogenic shock or hypotension IV (systolic BP < 90 mmHg).W IKIPEDIA. an S3.40 60 – 80 HTTP://EN.ORG/WIKI/KILLIP_CLASS . and evidence of peripheral vasoconstriction Mortality Rate (%) 6 17 30 .Prognosis KILLIP CLASSIFICATION Class Description no clinical signs of heart failure I rales or crackles in the lungs.

9 % risk of adverse cardiac event • High 5-7 : up to 41% risk of adverse cardiac event HTTP://DOKNOTES. ST deviation on admission > 1 mm • 7.hypertension. Troponin T • Low 0-2 : < 8.COM/TIMI-SCORE-FOR-UNSTABLE-ANGINA-AND-NSTEMI . family history.3% risk of adverse cardiac event • Intermediate 3-4 : < 19. smoking. dyslipidaemia • 3. At least 2 episodes of rest pain in the past 24 hours • 6. diabetes mellitus.CK. Age > 65 years • 2. More than 3 risk factors . Aspirin use in the past 7 days • 5. CKMB.TIMI score for UAP and NSTEMI • 1.WIKIDOT. Prior coronary angiogram showing > 50% stenosis • 4. Elevated cardiac markers .

Thank You .