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Presented by:
Nor Ezyan Syamin bt
Nor Yazmi
C 111 10 857
Supervisor:
dr. Abdul Hakim
Alkatiri, SpJP. FIHA
Patients Identity
Name
Age
Address
: Mr. H
: 64 years old
: Jl. Cakalang/5 Pappang
Campalagian Polman
Medical Record
: 699862
Date of admission : 19th March 2015
Anamnesis
*Chest pain
Chief complaint
Insert text
here
History of disease
History of lifestyle, smoking since 50 years
ago, 1-2 packs per day
Hypertension since 5 years ago and
uncontrolled
Diabetes Mellitus and cholesterol disease have
been denied
History of the same complaint have been
denied
Risk Factor
Non modified
Gender: Male
Modified
Hypertension
Physical examination
General status
GCS 15 (E4M6V5)
BW : 60 kg, BH : 165 cm, BMI : 22 kg/m2 (normal)
Moderate sickness / well nourished / conscious
Vital sign
BP: 120/80mmHg
Pulse : 72 bpm
Respiration rate : 20i/minute
Temp: 36,6 C
Physical examination
Head : anemic (-) icteric (-)
Neck : JVP R+2 cmH2O,
Lung :
Inspection
: symmetry left=right
Palpation
: mass (-), no tenderness, normal
vocal fremity
Percussion
: sonor
Auscultation : vesicular, ronchi +/+, wheezing -/-
Physical examination
Cor
:
Inspection : ictus cordis not visible
Palpation : ictus cordis not palpable, thrill (-)
Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra
Auscultation : I/II pure heart sound , regular, murmur
(-)
Physical examination
Abdomen :
Inspection
Auscultation
Palpation
Percussion
Electrocardiography
Interpretation
Sinus : Rhythm
Heart Rate :68 bpm
P Wave : 0.1
PR interval : 0.16
QRS complex :0.08
Axis : Normoaxis
ST-segment : depression at
V2-V5
T Wave : Inverted at II, III, aVF
Conclusion : Rhythmic sinus,
Electrocardiography (posterior)
Interpretation
Sinus : Rhythm
Heart Rate :74 bpm
P Wave : 0.1
PR interval : 0.16
QRS complex :0.08
Axis : Normoaxis
ST-segment : elevated at
V7-V9
T Wave : Inverted at II, III, aVF
Conclusion : Rhythmic sinus, heart rate 74 bpm,
normoaxis, ST-elevation at posterior region and
T inverted at inferior region.
Laboratorium (19/3/2015)
Complete Blood Count
Test
Result
Normal value
WBC
RBC
HGB
17,7 g/dl
12 16
HCT
50,5 %
37 48
PLT
Insert text
4.0 6.0 x 10
here
6
Blood Chemistry
Test
Result
Normal value
Ureum
40 mg/dl
Creatinine
1,1 mg/dl
10 50
L(<1,3); P(<1,1)
mg/dl
SGOT
29 mg/dl
<38
SGPT
39 mg/dl
<41
Uric acid
10,5 mg/dl
Sodium
140 mmol/l
Potassium
4,3 mmol/l
Chloride
103mmol/l
97-111 mm0l/l
Cardiac Enzymes
Test
CK
CK-MB
Troponin-T
Result
116 U/l
166,6 U/l
0,56 ng/ml
Normal value
<190
<25
< 0,05
Diagnosis
ST elevasion myocardiac
infarction inferior posterior
KILLIP II
Management
Bed rest
O22-4 liter /minute via nasal canule
IVFD NaCl 0,9 % 500 cc/24 hours
Anti-Platelet Agregation
Aspilet 160 mg (loading dose), maintenance 1x80 mg tab
Clopidogrel 300 mg(loading dose), maintenance 1x75 mg tab
Nitrat
Isosorbid dinitrate (Farsorbid) 10mg/8hours/oral
Isosorbid dinitrate 5mg/chest pain occurrence/subligual
Anti-coagulant
Fondaparinux (Arixtra)2.5mg/24hours/subcutaneous
Laksative
Laxadyn syrup 15cc/24hours/oral
Anti-anxiety
Alprazolam 0.5mg/24hours/oral
Thrombolitic
Streptokinase 1,5 million unit in Dextrose 5% 100 ml finish in an hour
Discussion
Acute Coronary Syndromes
(ACS)
Regions of Myocardium
Lateral
I,
AVL,V5V6
Inferior
II, III, aVF
Anterior /
Septal
V1-V4
Definition
Myocardial infarction (MI) rapid
development of myocardial necrosis
caused by a critical imbalance
between the oxygen supply and
demand of the myocardium.
This usually results from plaque
rupture with thrombus formation in
a coronary vessels, resulting in an
acute reduction of blood supply to a
portion of the myocardium
Pain Assessment
Onset: What was the patient doing when the signs and
symptoms first occurred?
Provocation: Is there anything that makes the symptom
better or worse?
Quality: Description of what the patient is feeling for
example the pain can be described as dull, sharp,
crushing, aching, tearing
Radiation/Region: Where is the pain located and does it
move to another part of the body?
Severity: How severe is the symptom based on a scale 1
to 10
Time: When did the signs and symptoms first occur?
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Pathophysiology
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Risk Factor
Modifiable
Smoking
Hypertension
Diabetes mellitus
Hypercholesterolemi
a
Obesity
Psychosocial stress
Lack of physical
activity
NonModifiable
Gender & Age
Men > 45 years old
Women > 55 years old
Family history
Heart disease in
biological brother or
father > 55 years old
Heart disease in
biological sister or
mother > 65 years old
DIAGNOSIS OF ACS
At least 2 of the following
Ischemic symptoms
Diagnostic ECG changes
Serum cardiac marker
elevations
DIAGNOSIS OF ACS
Ischemic symptoms
Prolonged pain (usually >20 mins) may also be
described as a dull pain, constricting, crushing, squeezing
Usually retrosternal location, radiating to left chest,
left arm; can be
epigastric
Dyspnea
Diaphoresis
Palpitations
Nausea/vomiting
Light headedness
Sense of impending doom
DIAGNOSIS OF ACS
At least 2 of the
following
Ischemic symptoms
Diagnostic ECG
changes
Serum cardiac
marker
elevations
ECG CHANGES
Hyperacute
Phase
Complete
Evolution
Specific STElevation
T inverted
Q-Pathologic
Old Infarct
Q-Pathologic
ST segment
isoelectric
T normal or
inverted
DIAGNOSIS OF ACS
At least 2 of the
following
Troponin T
Ischemic
CK-MB
symptoms
CK
Diagnostic ECG
Myoglobin
changes
Serum cardiac
marker
CARDIAC BIOMARKERS
MANAGEMENT
Complications
Systemic
Cardiogenic shock
Severe heart failure
Right ventricular infarction
Mechanic
al
Electrical
Ventricular arrythmia
Atrial Fibrilation and Other Supraventricular
Tachyarrhythmias
Bradicardia, Atrioventricular block
Others
Mitral regurgitation
Ventricular septal rupture
Left ventricular free wall rupture
Left ventricular aneurysm
Pericarditis
Thromboembolic & bleeding
Acute kidney injury
Hyperglycemia
Prognosis
KILLIP Classification
Class
Description
Mortality rate
(%)
II
17
III
30-40
IV
60-80
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Thank
You
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here