CASE REPORT CARDIOLOGY DEPARTMENT

Presented by:
Nishalani Elangovan C11108759
Supervisor:
Dr. Muzakkir Amir, Sp.JP, FIHA,FICA
PRESENTED IN THE CONTEXT OF CLERKSHIP
CARDIOVASCULAR DEPARTMENT
MEDICAL FACULTY
HASANUDDIN UNIVERSITY
2013

PATIENTS IDENTITY

Name
Age
Gender
MR
Day of Admission

:
:
:
:
:

Mr. A
63 years old
Male
600089
20/3/2013

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.

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 (+)

RISK FACTORS

PHYSICAL EXAMINATION
General Status:
Moderate illness/ Well nourished/ Conscious
Nutritional Status: Normal (BMI: kg/m)
Weight : 60 kg
BMI: 23.4 kg/m2
Height : 160 cm
Vital Signs:
Blood Pressure
Pulse Rate
Respiratory Rate
Temperature

: 140/90 mmHg
: 80 bpm
: 20 bpm
: 36.7 0C

Head and Neck Examinations:

Eye
: Conjunctiva anemic (-/-), Sclera icteric (-/-)
Lip
: Cyanosis (-)
Neck : JVP R +2 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 +/+ at the

base of the lungs,
Wheezing-/-

Cardiac Examination
Inspection
Palpation

palpable
Percussion

: Heart apex was not visible

: Heart apex was not

: 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(-)

Abdominal Examination
Inspection: Flat, follows breathing

movement
Auscultation : Peristaltic sound (+), normal
Palpation : No mass, no tenderness, no
palpable liver or spleen.
Percussion : Tympani (+)

Extremities Examination
Pretibial edema -/Dorsal pedis edema -/-

ELECTROCARDIOGRAM(20/3/
13)

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-V3
Conclusion : Sinus rhythm, HR 75
normoaxis, OMI inferior.

bpm,

LABORATORY FINDINGS
WBC

11.35 x 10/uL

GOT

44 U/L

RBC

4.41 x 10/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 10/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

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.

ECHOCARDIOGRAM
27/2/2013

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 %.

CORONARY ANGIOGRAPHY

Cannulation of LCA and RCA angiography

shows:
LM
LAD

80
after
LCX
RCA
LCX

: Normal
: Diffuse stenosis prox-distal, small vessel,
% stenosis after D1, 75-80% stenosis
D2
: Proximal stenosis 80-90%, small vessel
: Proximal total occlusion, distal filled from

Conclusion: CAD 3 VD, small vessel

Suggestions: Conservative

WORKING DIAGNOSIS

NSTEMI
HYPERTENSION grade I

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

DEFINITION

European Heart Journal 2012: ESC Guidelines

ANATOMY

American Heart Association: http://watchlearnlive.heart.org

PATHOPHYSIOLOGY

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

RISK FACTORS
Non-Modifiable
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

Modifiable

Smoking

Hypertension

Diabetes

Dyslipidemia

Obesity

Lack of physical
activity

Mellitus

DIAGNOSIS

Oxford Handbook of Clinical Medicine 6 th Edition

CLINICAL MANIFESTATIONS

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

MANAGEMENT

Coronary Heart Disease in Clinical Practice