Download - Nstemi
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Supervisor:
Dr. Muzakkir Amir, Sp.JP, FIHA,FICA
PRESENTED IN THE CONTEXT OF CLERKSHIPCARDIOVASCULAR DEPARTMENT
MEDICAL FACULTYHASANUDDIN UNIVERSITY
2013
Presented by:
Nishalani Elangovan C11108759
CASE REPORT CARDIOLOGY DEPARTMENT
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PATIENT’S IDENTITY
Name : Mr. A Age : 63 years
old Gender : Male MR : 600089 Day of Admission : 20/3/2013
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HISTORY TAKING CHIEF COMPLAINT: Chest pain Anamnesis:
It was felt since ± 1 year ago and got worsen 2 days before admitted to the hospital. Chest pain was felt on left side with the characteristics of heavy feeling on the chest, duration of pain was >20 minutes, radiates to the left arm and to the back. The pain exacerbates with exercise and not lessen with rest. Chest pain accompanied by shortness of breath. Dyspnea on effort (+), Orthopnea (-), Paroxysmal Nocturnal Dyspnea (-), Cough (-). Fever (-) Nausea (-) Vomit (-) Palpitation (-), Cold sweats (-). Defecation and urination: normal.
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PAST MEDICAL HISTORY History of diabetes (-) History of hypertension (+) since 4 years ago with
controlled therapy. History of dyslipidemia is denied. History of hyperuricemia is denied. History of smoking (+) since 45 years ago but
stopped 1 month before admitted to the hospital. 1 box per day.
History of cardiovascular disease in family (-) History of asthma (+)
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RISK FACTORS
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PHYSICAL EXAMINATION
General Status:Moderate illness/ Well nourished/ ConsciousNutritional Status: Normal (BMI: kg/m²)Weight : 60 kg BMI: 23.4 kg/m2
Height : 160 cm
Vital Signs:Blood Pressure : 140/90 mmHgPulse Rate : 80 bpmRespiratory Rate : 20 bpmTemperature : 36.7 0C
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Head and Neck Examinations:Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-) Lip : Cyanosis (-)Neck : JVP R +2 cmH₂O
Chest ExaminationInspection : 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 +/+ at the base of the lungs,
Wheezing-/-
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Cardiac Examination– Inspection : Heart apex was not
visible – Palpation : Heart apex was not
palpable – Percussion : Right heart border in
right parasternal line, left heart border in left midclavicular line ICS V.
– Auscultation : Heart Sounds : S I/II regular, murmur (-) gallop(-)
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Abdominal ExaminationInspection : Flat, follows breathing
movementAuscultation : Peristaltic sound (+), normalPalpation : No mass, no tenderness, no
palpable liver or spleen.Percussion : Tympani (+)
Extremities ExaminationPretibial edema -/-Dorsal pedis edema -/-
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ELECTROCARDIOGRAM(20/3/13)
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ECG Interpretation Rhythm : Sinus rhythm HR / QRS rate : 75 bpm Axis : Normoaxis Regularity : Regular P wave : 0.08 s (N: 0.08-0.12 s) PR interval : 0.12 s (N: 0.12-0.20 s) QRS complex : 0.08 s (N: 0.06-0.11 s) ST segment: Normal T wave : T inverted V1-V3Conclusion : Sinus rhythm, HR 75 bpm,
normoaxis, OMI inferior.
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LABORATORY FINDINGS
WBC 11.35 x 10³/uL GOT 44 U/L
RBC 4.41 x 10⁶/uL GPT 45 U/L
HB 12.8 g/dL Electrolytes (Na, K, Cl) 135, 4.8, 102 mmol
HCT 40.4 % Total Cholesterol 180 mg/dL
PLT 309 x 10³/uL LDL Cholesterol 131.6 mg/dL
GDS 73 mg/dL Triglyceride 72 mg/dL
Ur 31 mg/dL HDL Cholesterol 40 mg/dL
Cr 1,2 mg/dL Troponin T 1722
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CHEST X-RAYS 20/3/2013 Bronchovascular pattern
within normal limit. No specific process on both
lungs Enlargement of the cardiac
with CTI >0.5 , concave cardiac waist , elevated apex, dilated, elongated of aorta.
Both sinus and diaphragm in good conditions.
Bones are intact.
Conclusion: Cardiomegaly Dilation, elongation of aorta.
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ECHOCARDIOGRAM 27/2/2013
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Description of Wall Motion, Masses, Valves, Pericardium
Dilated LA LVH (+) Decrease LV Contractility, EF 50 % Global Hypokinetic Heart valves:
Mitral: MR trivial. others: Normal
E/A<1
TAPSE 1,8cm
Conclusion:• Systolic and
diastolic dysfunction LV ec CAD
• Global hypokinetic EF 50 %.
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CORONARY ANGIOGRAPHY
Cannulation of LCA and RCA angiography shows:LM : NormalLAD : Diffuse stenosis prox-distal, small
vessel, 80 % stenosis after D1, 75-80% stenosis after D2
LCX : Proximal stenosis 80-90%, small vesselRCA : Proximal total occlusion, distal filled
from LCX Conclusion: CAD 3 VD, small vessel Suggestions: Conservative
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WORKING DIAGNOSIS
NSTEMIHYPERTENSION grade I
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MANAGEMENT O2 2 -4 Lpm Bed rest IVFD NaCl 0.9% 10 dpm Antiplatelet ---- Aspilet 80 mg 0-1-0 Antiplatelet ---- Plavix 75 mg 0-0-1 Nitrate ---- Cedocard 1 mg/hour/SP Loop diuretic ---- Furosemide 1 amp/12h/IV ACE-Inhibitor ---- Captopril 25 mg 1-1-1 Anticoagulants ---- Lovenox 0.6cc/12h/SC Statin ---- Simvastatin 20 mg 0-0-1 Anti anxiety ---- Alprazolam 0.5 mg 0-0-1 Laxative ---- Laxadyn syr 0-0-2c Fluid balance ECG per day
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DEFINITION
European Heart Journal 2012: ESC Guidelines
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ANATOMY
American Heart Association: http://watchlearnlive.heart.org
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PATHOPHYSIOLOGY
American Heart Association: http://watchlearnlive.heart.org
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American Heart Association: http://watchlearnlive.heart.org
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American Heart Association: http://watchlearnlive.heart.org
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American Heart Association: http://watchlearnlive.heart.org
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American Heart Association: http://watchlearnlive.heart.org
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American Heart Association: http://watchlearnlive.heart.org
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Gender and Age
Men, increased risk > age 45
Women, increased risk > age 55
Family History
CAD diagnosed before age 55 in
father or brother
CAD disease diagnosed before
age 65 in mother or sister
Non-Modifiable Smoking
Hypertension
Diabetes Mellitus
Dyslipidemia
Obesity
Lack of physical
activity
Modifiable
RISK FACTORS
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DIAGNOSIS
Oxford Handbook of Clinical Medicine 6th Edition
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CLINICAL MANIFESTATIONS
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ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal (2011)
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MANAGEMENT
Coronary Heart Disease in Clinical Practice
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