SOAP

CHEST PAIN
Syarif Hidayat, SpJP, FIHA
RSUD dr. Dradjat Prawiranegara,
Serang

Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga

1
Kesehatan, Cilegon, 2-4 Mei 2016
Introduction
Chest pain the foremost manifestation of myocardial ischemia results
from a disparity between myocardial oxygen demand and coronary
blood flow

The most common causes of myocardial ischemia are coronary

atherosclerosis, coronary vasoconstriction, and coronary artery
thrombosis

The differential diagnosis of chest pain is extensive. Gastrointestinal

diseases, psychogenic diseases, neuromuscular diseases, and diseases
of the pulmonary system

Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga

2
Kesehatan, Cilegon, 2-4 Mei 2016
C
H
s • SUBJECTIVE CHIEF
COMPLAINT

E
S o • OBJECTIVE FINDINGS

T
P
A
A • ASSESSMENT DIAGNOSIS

I
N P • PLAN
WHAT WILL
DO TO TREAT

Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga

3
Kesehatan, Cilegon, 2-4 Mei 2016
SUBJECTIVE
A Onset Acute Gradual (acute
Chronic
on chronic)
N
A
M Seven cardinal Typical, angina,
Type
symptoms infarct, ACS
N
E
S
Onset Type History
A

Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga

4
Kesehatan, Cilegon, 2-4 Mei 2016
 Seven cardinal symptoms

Location Anterior midchest, radiate, diffuse

Tightness, squeezing, heaviness, pressure, and

Quality constriction

Chronology Less than 20 minutes

Quantity The severity & progressivity angina varies

Setting Certain times or activities

Related to stress and is relieved by ending or

Aggravating/ alleviating factors controlling the stress (physical/emotion)

Nausea, vomiting, faintness, fatigue, or

Associated symptoms diaphoresis
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
5
Kesehatan, Cilegon, 2-4 Mei 2016
 TYPE
Typical Angina Infarct ACS
• Substernal • Sternum • More severe & • Angina first
• (+) By activity/ • Difuse, dullness, More longer onset (CCS III)
emotion radiated, (>20min) • Angina
•  By resting/ symptom, + • Not relieve by cressendo (CCS
nitrate 10min resting/ nitrate III pd APS)
• Provoked by • Angina at rest
activity/ emotion • Angina post MI
• Relieve by
resting/ nitrate
Angina equivalen/ silent ischemia
• Dyspnea, palpitation, syncope, chest discomfort
• Younger/ older, woman, DM, CRF, dementia
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
Kesehatan, Cilegon, 2-4 Mei 2016 6
 Obtain HISTORY

MEDICAL SOCIAL
CAD, DM, DYSLIPIDEMIA,
SMOKER, ALCOHOL,
FAMILY HISTORY, HTN,
SEDENTARY LIFE, PHYSICAL
OBESE, MENOPAUSE,
ACTIVITY
THERAPY
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
7
Kesehatan, Cilegon, 2-4 Mei 2016
OBJECTIVE

Appearance
R
E
V
I Vital sign
E
W
Physical examination
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
8
Kesehatan, Cilegon, 2-4 Mei 2016
Appearance
•General status (mild, moderate,
severe)

Vital sign
•BP, HR, RR, temperature, saturation

Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga

9
Kesehatan, Cilegon, 2-4 Mei 2016
Physical examination
• Mental status
• Head : anemic, icteric, cyanosis
• Neck : JVP, bruit, thyroid gland
• Cor : ictus cordis, parasternal heaving;
percussion; heart sound, murmur, gallop
• Pulmo : vesicular, rales, wheezing
• Abdomen : hepatosplenomegaly, asites
• Extremity : cyanosis, edema, pulsation
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
10
Kesehatan, Cilegon, 2-4 Mei 2016
ASSESMENT
D C H E S T PA I N
I TIGHTNESS PRESSURE HEAVINESS STRANGLING COMPRESSION

A
G
DIFFERENTIAL DIAGNOSIS
N
CARDIAC DISORDERS NON CARDIAC DISORDERS
O
S
I CARDIAC DISORDERS
S ISCHEMIC – INFARCT OTHERS

Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga

11
Kesehatan, Cilegon, 2-4 Mei 2016
Ischemic – infarct
• APS, ACS (UAP/NSTEMI/STEMI)

Others
• Aortic valve stenosis, mitral valve prolapse,
hypertrophic cardiomyopathy, pericarditis,
pulmonary embolus, systemic arterial
hypertension, aortic dissection
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
12
Kesehatan, Cilegon, 2-4 Mei 2016
PLAN

S ECG
T Oxygen O
A B
B
I T Chest x-ray
L A
I
I
Z
E
Drug N Laboratory
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
13
Kesehatan, Cilegon, 2-4 Mei 2016
S
Oxygen
T • Position
• Nasal, rebreathing, nonrebreathing, CPAP,
A Ventilator
B • iv line, monitor
I
L
Drug
I • MONA (MORPHINE, O2, NITRATE, ASPIRIN)
• Anti thrombotic, anti coagulant, anti ischemic
Z (CCB/BB), statin, analgetics, tranquilizer, laxative
E • Preload, afterload, contractility
• Anti arrhythmic
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
14
Kesehatan, Cilegon, 2-4 Mei 2016
 ECG
O • ST/arrythmia (AVB, AF, atrial flutter, VT),
B LAE/RAE, LVH/RVH, ST segment elevation
/depression, T wave inversion, PAC/PVC
T
A Chest x-ray
I • CTR >, Ao >, pulmonary segment, LVH/RVH,
LAE/RAE, pulmonary vascularization
N
Laboratory
• Hb, Ht, L, Tr, GDS, OT/PT, Ur/Cr, Na/K, blood
gas analysis, enzym (CKMB, Troponin, BNP)
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
15
Kesehatan, Cilegon, 2-4 Mei 2016
KASUS

Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga

16
Kesehatan, Cilegon, 2-4 Mei 2016
 TTV : TD 166/94, N 96x/m, R
KASUS 1 Sakit dada sejak
0 1 thn yl
16x/m, S 36,5 C, sat 98%
s
PF/ : batas kiri jantung 2 jari lateral
Memberat
midclavicula sxsejak
ICS V 2mgg
Pria,
o 62tahun, linea datang ke
poliklinik1).dgn
APS CCSsakit
II sp CAD, 2).dada
Sakit dada kiri, timbul jika aktifitas spt
sp HHD,
jalan 100m/ naik tangga, berkurang jika
HT stage II, 3). dislipidemia
istirahat
A 1). Batasi aktifitas, hindari stress, diit rendah
Sakit dada seperti tertekan, lengan kiri
garam dan lemak; 2). a-trombotik,
pegal, keringat
simvastatin, dingin
bisoprolol, (+), ISDN
ACE-I, < 10 slmenit
kp/

P Riwayat HT &
dislipidemia EKG, rontgen torak,
Th/ laboratorium,
HT tidak hafal, Smoker (+)
kontrol ulang
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
stop 1 bulan ini Kesehatan, Cilegon, 2-4 Mei 2016 17
 STEMI
Sesakanterior
EKG,
nafasextensif
rontgen
berat, onset 6jam, bisa
torak,
tidak CAD,
KASUS 2 CHF, DM tipe2, HT stg I, riw HT emergensi,
ALO laboratorium
bernafas, seperti tenggelam
s riwayat

Onset
MONA, 6jam,
Clopidogrel,
sesak dgnREPERFUSI
chestNdiscomfort,
(primary
TTV
pertama
: TD 226/122,
PCI), simvastatin,
kali, saat furosemid,
sedang bicara
124x/m,
ACE-I,
& nonton
Wanita, 52tahun, datang ke
Rtranqulizer,
36-40x/m, S &kontrol
37,6 0C,tidak
satrutin
88%
o
EMG dgn keluhan
TV, riwayat DOE,
laxative,

sesak
PF/ : ronkhi seluruh
DM

lapangberat
paru,
HT, th/
GDS

TTV : TD 166/98, N 92x/m, R 16-

asites (+), edem tungkai (+), akral
18x/m, sat 96%
hangat
A PF/Edem
: ictus kordis
paru teraba
akut 3 jariHT
dgn lateral
linea midclavicula sx, ronkhi basah
emergensi, sp CHF
halus <1/3 lapang paru,
P Posisi duduk; O2 NRM; furosemid
GDS 336, CKMB 77, troponin 2,2
iv, ISDN sl  iv, MO iv
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
Kesehatan, Cilegon, 2-4 Mei 2016 18
Tentative Peningkatan Kapasitas Petugas Pelayanan Terpadu Bagi Tenaga
Kesehatan, Cilegon, 2-4 Mei 2016 19