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UNSTABLE ANGINA PECTORIS TIMI SCORE 4/7

By: Nur Sepdyanti (C11108342) Supervisor: dr. Khalid Shaleh SpPD

PATIENT IDENTITY
Name Age Gender Medical record Date of admission : Mr. L.H.B : 71 years old : Male : 568120 : 13 th September 2012

HISTORY TAKING
Chief complaint: Chest pain Guided anamnesis: Occured since 4 days ago, getting worse 1 day before admission. The patient complain of pain on the left side of chest, non radiated The pain felt like pin and needle feeling. Intermittent pain, frequency of recurrent attack > 5 times a day with increasing intensity, duration about 5-10 minutes. The pain doesnt triggered by activity and not relieved by resting. DOE (+) arises especially when chest pain relapse. Nausea (-), Vomiting (-),PND (-), orthopneu (-).

PAST ILLNESS HISTORY


- History of hypertension since 5 years ago, treatment irregularly. - Smoking (+) since 30 years ago - Family history of heart disease (-) - History of dyslipidemia (unknown) - History of DM (unknown)

CLINICAL EXAMINATION
GENERAL STATE Moderate illness/normoweight/conscious VITAL SIGN Blood pressure : 150/80 mmHg Pulse : 80 bpm Breathing : 22 x/minute Temperature: 36.70C

Head Examination Eyes : anemic -/-, icterus -/ Lip : cyanosis (-) Neck : lymphadenopathy (-), JVP R-2 cmH2O Chest Examination Inspection : symmetric R=L, normochest Palpation : mass (-), tenderness (-), VF R=L Percussion : sonor Auscultation : breath sound :vesicular additional sound : ronchi -/wheezing -/-

Cardiac Examination Inspection : IC wasnt visible Palpation : IC palpable Percussion : normal heart size
-Upper border -Lower border -Right border -Left border

Auscultation (-)

: Regular of I/II heart sound, murmur

: left 2nd ICS : left 5th ICS : right parasternalis line : left medioclavicular line

Abdominal Examination Inspection : flat and following breath movement Auscultation : peristaltic sound (+) ,normal Palpation : liver and spleen unpalpable Percussion : tympani, ascites (-) Extremities - Oedema : pretibial -/-, dorsum pedis -/-

ELECTROCARDIOGRAM
Rhythm: sinus rhythm QRS rate: HR 69 bpm P wave : 0.06 sec PR interval: 0.12 sec QRS complex: 0.08 sec Axis: Normo axis ST segment: isoelectric T-wave inverted: I, AvL, V5, V6 Conclusion: sinus rhythm Hr= 69 bpm, lateral wall myocard ischemia

LABORATORY FINDING
Test
WBC RBC HGB HCT MCV MCH MCHC PLT

Result
7,23x103 mm3 5,35 x 106 mm3 14,5 g/dl 44,3 % 82,8 fL 27,1 pg

Normal value 4,0-10,0 x 103 mm3 4,0-6,0 x 106 mm3 13,0-17,0 g/dl 40,0-54,0 % 80-100 fL 27,0-32,0 pg 32-38 g/dL 150-500 x 103

32,7 g/dL
238 x 103 /uL

LABORATORY FINDING
Test
GDS Ureum Creatinin SGOT SGPT Total Cholesterol HDL LDL 110 20 1,0 19 11 156

Result 110

Normal value 10-50 M(<1,3);F(<1,1) <38 <41 200 M(>55);F(>65) <120

26
75

LABORATORY FINDING
Test
Trigliserida CK 51 104

Result 200 M(<

Normal value

CK-MB
Troponin T Uric Acid

13
7,4

<25
F(2,4-5,7), M(3,4-7,0)

WORKING DIAGNOSIS
Unstable angina pectoris HT Grade I on treatment

THERAPY
O2 2-4 liters/minute IVFD NaCl 0,9 % 500cc/24hour Farsorbid 5 mg/SL (when chest pain occured) Farsorbid 10 mg 1-1-1 Antiplatelet: Aspilet 80 mg 1-0-0 Clopidogrel 75 mg 0-1-0 Anti Hypertension: Lisinopril 5 mg 0-0-1 Simvastatin 20 mg 0-0-2 Alprazolam 0.5mg 0-0-1 Laxadyn Syrup 0-0-2 Arixtra 2.5 mg/day/SC

DISCUSSION

CAD
CAD

ACS

Stable Angina Pectoris

UAP

NSTEMI

STEMI

DEFINITION
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.

CLASSIFICATION
Based on CANADIAN CARDIOVASCULAR SOCIETY FUNCTIONAL CLASSIFICATION

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.

UNSTABLE ANGINA
angina at rest (> 20 minutes) new-onset (< 2 months) exertional angina (at least CCSC III in severity) recent (< 2 months) acceleration of angina (increase in severity of at least one CCSC class to at least CCSC class III)

PATHOGENESIS
Plaque rupture Thrombus formation Incomplete/ intermittent occlusion of the infactrelated vessel to the presence of collateral channels/ to small size of affected vessel.
Cardiology, Desmond G. Julian, J.Campbell Cowan, James M. McLenachan, 8th edition, Elsevier, 2005

RISK FACTOR

Modifiable : - Smoking - Dyslipidemia - Raised Blood pressure - Diabetes melitus - Obesity

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

DIAGNOSE

TIMI RISK FACTOR

MANAGEMENT
stabilizing any plaques that may have ruptured in order to prevent a heart attack,

relieving symptoms treating the underlying coronary artery disease (CAD)

MANAGEMENT

THANK YOU