Beruflich Dokumente
Kultur Dokumente
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
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
: No mass, no tenderness.
Cardiac Examination
Inspection
Palpation
palpable
Percussion
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
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
Conclusion:
Cardiomegaly
Dilation, elongation of aorta.
ECHOCARDIOGRAM
27/2/2013
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
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
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
ANATOMY
PATHOPHYSIOLOGY
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
CLINICAL MANIFESTATIONS
ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment
elevation. European Heart Journal (2011)
MANAGEMENT