By : YUDITH DWI WIKEN

C111 09 340
Supervisor:
dr. Abdul Hakim Alkatiri, Sp.JP .FIHA
Department Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2014

Name
Age
Address
Medical record
Date of admission

: Mr. M
: 73 years old
: Manggala
: 3043
: October 28th 2014

Chief complaint:
Chest pain
Guided anamnesis:
It was felt 11 years ago,getting worse since 2 days
before admitted to the hospital. It felt like stabbed by
something,but did not spread in the left arm.The pain
was felt more than 30 minutes. The pain isnt
influence by activity and didnt getting better if the
patient taking a rest.There is history of ring insertion
on 2003, and there is history of catheterization in
2013.

History of diabetes (+)

History of hypertension (+)
History of dyslipidemia is denied.
History of hyperuricemia (-)
History of smoking (-)
History of cardiovascular disease (+), He had
ring insertion on 2003 and cateterization on
2013, with the result CAD 3 VD + LM dissease
.
History of cardiovascular disease in family (-)

Non-Modified Risk Factor :

Gender : Male
Age: > 45 years old

Modified Risk Factor :

Diabetes Mellitus (+)
Hypertension (+)

GENERAL STATE
Moderate illness/ Well nourished/ Conscious
Nutritional Status: Normal (BMI: kg/m)
Weight : 60 kg
Height : 160 cm

VITAL SIGN
Blood pressure
Pulse
Breathing
Temperature

BMI: 23.4 kg/m2

: 140/80 mmHg
: 63 times/min
: 22 times/min
: 36,50C (Axilla)

Head and Neck Examinations:

Eye
: Conjunctiva anemic (-/-), Sclera icteric (-/-)
Lip
: Cyanosis (-)
Neck
: JVP R +1 cmHO
Chest Examination
Inspection : Symmetric between left and right chest.
Palpation : No mass, no tenderness.
Percussion : Sonor between left and right chest,
lung-liver border in ICS IV right anterior.
Auscultation: Respiratory sound: Vesicular
Additional sound : Ronchi -/-. Wheezing -/-

Cardiac Examination
Inspection
: IC was not visible
Palpation
: IC was not palpable
Percussion
: Right heart border in right
parasternal line, left heart border two fingers
from left midclavicular line ICS VI.

Auscultation
: Regular of I/II heart sound, no gallop, no
additional sound

Abdominal Examination
Inspection

: flat, following breath movement

Auscultation

: Peristaltic sound (+), normal

Palpation

: No mass, no tenderness, no palpable liver and

spleen

Percussion

: Tympani (+), ascites (-)

Extremities Examination
Pretibial edema -/-

Dorsum pedis edema -/-

Rhythm : sinus rhythm

QRS rate : HR 75 bpm
Axis : LAD
P wave : 0.08 sec
PR interval : 0.16 sec
QRS complex : 0.12 sec
QS configuration V1-3
ST segment elevation : V1, V2, V3
ST segment depression II, III, aVF

T inverted : L1, AVL

Conclusion : sinus rhythm Hr= 75 bpm, LAD, OMI anteroseptal,

ischemic high lateral et inferior wall

Test

Result

Normal value

WBC

7.7 x103 /l

4,0-10,0 x 103 /l

RBC

3,77 x 106 /l

4,0-6,0 x 106 /l

HGB

12,0 g/dl

13,0-17,0 g/dl

HCT

344.0 %

40,0-54,0 %

MCV

90 fL

80-100 fL

MCH

31.0 pg

27,0-32,0 pg

MCHC

35.4 g/dl

32-38 g/dl

PLT

243x 103 /l

150-500 x 103 /l

Test

Result

Normal value

GDS

121

140 mg/dl

Ureum

36

10-50 mg/dl

Creatinin

0,9

M(<1,3);F(<1,1) mg/dl

SGOT

18

<38 U/l

SGPT

17

<41 U/l

Total Cholesterol

167

200 mg/dl

HDL

55

M(>55);F(>65) mg/dl

LDL

143

<130 mg/dl

TG

91

200 mg/dl

Urid acid

6.4

M(3,4-7,0): F(2,4-5,7)
mg/dl

Test

Result

Normal value

Na

143

136-145 mmol/L

4.2

3,5-5,1 mmol/L

Cl

109

97-111 mmol/L

CK

45

M(<190) P(<167) U/l

CK-MB

13

<25 U/l

Troponin T

Negatif

Negatif

Unstable Angina Pectoris

Diabetes Mellitus

O2 2 -4 Lpm via NK
IVFD NaCl 0.9% 20 tpm
Cedocard 1 mg/jam/sp
Arixtra 2,5 mg/24 jam/subkutan
Miozidine 35 mg/12 jam/oral
Clopidogrel 75 mg/24 jam/oral
Bisoprolol 5 mg/24 jam/oral
Valsartan 160 mg/24 jam/oral
ISDN 5 mg/sublingual
Glimeprinide 2 mg/24 jam/oral
Metformin 500 mg/12 jam/oral

Evaluation of the vital sign

Chest X-Ray
Echocardiography

DISCUSSION

CAD

UAP

ACS

Stable Angina
Pectoris

NSTEMI

STEMI

Angina pectoris is a syndrome characterized by chest pain resulting from

an imbalance between O2 supply & demand, and is most commonly
caused by the inability of atherosclerotic coronary arteries to perfuse the
heart under conditions of increased myocardial O2 consumption.

Based on CANADIAN
CLASSIFICATION

CARDIOVASCULAR

SOCIETY

FUNCTIONAL

CLASS I No angina with ordinary activity. Angina with strenuous, rapid or

prolonged exertion.

CLASS II Slight limitation of ordinary activity ; angina when walking up

stairs briskly, or walking on a cold or windy day.

CLASS III Marked limitation ; angina when walking at normal pace up

flight of stairs, or walking 1-2 blocks distance.

CLASS IV Angina on minimal exertion or at rest.

Plaque rupture
Thrombus formation
Incomplete/ intermittent
occlusion of the infarctrelated vessel

Cardiology, Desmond G. Julian, J.Campbell Cowan, James M.

McLenachan, 8th edition, Elsevier, 2005

RISK FACTOR

Modifiable :
- Smoking
- Hypertension
- Dyslipidemia
- Diabetes mellitus
- Obesity

Non-Modifiable :
- Family History of CVD
- Age
- Gender

ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment
elevation. European Heart Journal (2011)

Coronary Heart Disease in Clinical Practice

Congestive Heart Failure (CHF)

Heart Failure

Congestive

Heart Failure

Heart is no longer able to

pump an adequate supply of
blood in relation to the venous
return and in relation to the
metabolic needs of the body
tissues at the particular moment

The state in which abnormal

circulatory congestion occurs as
the result of heart failure.

Etiology of
Heart Failure

Main Causes
Ischemic heart disease (35%40%)

Cardiomyopathy(dilated)
(30-40%)

Hypertension ( 15-20%)

Other Causes

Arrhythmias
Valvular heart disease
Congenital heart disease
Pericardial disease
Hyperdynamic
circulation
Alcohol and
drugs(chemotherapy)

Major Criteria

Minor Criteria

Paroxysmal Nocturnal Dyspnea

Extremity edema

Cardiomegaly

Nocturnal cough

Gallop S3

Decreased vital pulmonary

Hepatojugular reflux

capacity (1/3 of maximal)

Increased of JVP

Hepatomegaly

Rales or ronchi

Pleural effusion

Acute pulmonary edema

Tachycardia ( 120bpm)

Prolonged circulation time(> 25 sec)

Dyspnea deffort

Weigh loss 4,5 kg in 5 days in

response to treatment of CHF

Plaque in
coronary artery

Blood flow to
heart muscle is
reduced. Heart
muscle lacking of
oxygen

Ischemia of heart
muscle can lead to
myocardial
infarction

Symptomatic
Congestive Heart
Failure

Pulmonary edema
Abnormal Heart
rhythm

The heart muscle

cant pump
adequately