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Morning Report

Monday, Dec 18th 2017

Physician in charge
ER : dr. Olivia
Identity

 Name : Mrs. K
 Age : 77 y.o
 Address : Jl. Pulosari V/15, Blimbing – Malang
 Job : Housewife
 No RM : 17028913
SUMMARY OF DATA BASE

Mrs. K/ 77 yo/ ER
Chief complaint :
Chest pain

Patient delivered by her family to ER RSL because she has been


having chest pain since yesterday. Pain occurs with walking and
transferred to her neck, left arm, and her shoulder. She has
epigastric pain, nausea and vomit. She also has cough for a week
and often cold sweats.

Previous History : DM (-) Cholesterol (+)


HT (-) Uric Acid (+)
Physical Examination
General appearance Looked severity ill GCS : 4 5 6, W±70kg, looked
overweight
Blood Pressure (ER) 90/ 60 mmHg
Pulse Rate 90 tpm,
Respiration rate 20 tpm
T ax 36,7 0C
02 sat 89%  98% on nasal canul
Head Anemic - , ict -
Neck JVP R + 1 cmH2O at 30 0
Chest Heart Ictus invisible, palpable ICS V MCL (S)
RHM SL (D), LHM≈Ictus
S1 S2 single murmur (-) gallop (-)
Lung Symmetric SF D=S , ronchy (+), no wheezing

Abdomen Flat, soefl BS (+) N, Liver span 8 cm, traube space


tympani
Extremities Ed -/-, warm acral, no oedema
ECG in ER
ECG in ER
Normal sinus rhytm
Heart rate 83 bpm
Inferior infarct, possibly acute
Laboratory finding Value
GDA 156 g/dL
Hemoglobine 12,6 gr/dl 11,0 – 16,1
Hematocrit 37,1 % 35 - 47
Leucocyte 8.590 ribu/uL 4.400 - 11.300
Trombocyte 200.000 /µL 150.000 – 440.000
Ur 24,8 mg/dl 21,00-43,00
Cr 0,75 mg/dl 0,60-1,10
Na 141,0 mmol/L 135-145
K 4,03 mmol/L 3,5-5,5
Cl 113,3 mmol/L 85-168
Rontgen Thorax PA

Cor : membesar ke kiri, CTR 60%,


apex tertanam
Pulmo : tampak fibroinduratif pada
lapangan atas kiri thoracalis.
Pulmonal vascularity normal.
Kedua sinus phrenicocostalis
dan hemidiapragma normal.
Kesimpulan :
1. Cardiomegali, LVH
2. TB paru, kemungkinan tidak aktif
Data at ER RSL

Physical exam WDx treatment


BP 90/60 HR 90 RR 20 Acute miocard infark - IVFd NS 20 tpm
warm acral (STEMI Inferior?) - Nebulizer C:P 1:1
GDA : 156 - Ketorolac inj 1x30mg
- Ranitidine inj 1x50mg
- Sotatic inj 1x10mg
- Aspilet 4x75mg
- Clopidogrel 4x80mg
 Thankyou
DEFINITIONS

 CAD is a continuum of disease….


Angina -> unstable angina -> AMI -> sudden cardiac death

 Acute coronary syndrome encompasses unstable angina, NSTEMI,


STEMI

 Stable angina – transient episodic chest pain d/t myocardial ischaemia,


reproducible, frequency constant over time.usually relieved with
rest/NTG.

 Classification of angina – Canadian Cardiovascular Society


classification.
Canadian Cardiovascular Association Classification of
Angina

CLASS 1 NO PAIN WITH ORDINARY PHYSICAL ACTIVITY

CLASS 2 SLIGHT LIMITATION OF PHYSICAL ACTIVITY –


PAIN OCCURS WITH WALKING, CLIMBING
STAIRS,STRESS

CLASS 3 SEVERE LIMITATION OF DAILY ACTIVITY – PAIN


OCCURS ON MINIMAL EXERTION

CLASS 4 UNABLE TO CONDUCT ANY ACTIVITY WITHOUT


PAIN, PAIN AT REST
 UNSTABLE ANGINA –
 Pain occurring at rest – duration > 20min, within one week of first visit
 New onset angina – ~ Class 2 severity, onset with last 2 months
 Worsening of chest pain – increase by at least 1 class, increases in
frequency, duration
 Angina becoming resistance to drugs that previously gave good control.

 NB! ECG – normal, ST depression(>0.5mm), T wave changes


 ACUTE MYOCARDIAL INFARCTION –
 ECC/ACC DEFN –rise and fall in cardiac enzymes with one or more of
the following:
 Ischaemic type chest pain/symptoms
 ECG changes – ST changes, pathological Q waves
 Coronary artery intervention data
 Pathological findings of an acute MI

 NSTEMI = UNSTABLE ANGINA SYMPTOMS/FINDINGS + POSITIVE


CARDIAC ENZYMES
 STEMI = ST ELEVATION ON ECG + SYMPTOMS
The Thrombus in STEMI
STEMI is generally caused by a Results from stabilization by fibrin
completely occlusive fibrin-rich mesh of a platelet aggregate at site of
thrombus in a coronary artery plaque rupture

*RBC = red blood cell.


GP IIb-IIIa inhibitors are not indicated for
STEMI.
Van de Werf F. Thromb Haemost.
1997;78(1):210-213; White HD. Am J Cardiol.
1997;80(4A):2B-10B;
Davies MJ. Heart. 2000;83(3):361-366.
STEMI cardiac care
• Determine preferred reperfusion strategy
Fibrinolysis preferred if: PCI preferred if:
 <3 hours from onset  PCI available
 PCI not available/delayed  Door to balloon < 90min
 door to balloon > 90min  Door to balloon minus door to
 door to balloon minus door needle < 1hr
to needle > 1hr  Fibrinolysis contraindications
 Door to needle goal <30min  Late Presentation > 3 hr
 No contraindications  High risk STEMI
 Killup 3 or higher
 STEMI dx in doubt
STEMI cardiac care
• Assessment
- Time since onset of symptoms
90 min for PCI / 12 hours for fibrinolysis
- Is this high risk STEMI?
- KILLIP classification
- If higher risk may manage
with more invasive rx
- Determine if fibrinolysis candidate
- Meets criteria with no contraindications
- Determine if PCI candidate
- Based on availability and time to balloon rx
Acute Phase Risk Stratification:
Importance of LV dysfunction
Killip Classification % patients Mortality (%)

I No CHF 30-50 5

II Rales, S3, Pulmonary venous hypertension 33 15-20

III Pulmonary edema 15 40

IV Cardiogenic shock 10 80-100

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