laporan kasus cardio (fransiska_c11107156)
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CASE REPORT, SEPTEMBER 2011
Presented by:Fransiska C. Subeno (C11107156)
Supervisor:dr. Abdul Hakim Alkatiri, Sp.JP, FIHA
STEMI Extensive Anterior Wall
PATIENT’S IDENTITY
Name : Mr. AAge : 52 years oldRegister no. : 47 82 46Date of admission : September, 4th 2011
HISTORY TAKING
Chief complaint : Chest pain
It has been felt since four hours before admitted to the hospital. The history of chest pain had been felt since two days ago, lost and appeared, but since 08.30 a.m. on the day he was admitted, it was felt continuously, sometimes he felt like strangulated. Cold sweat (+) everytime he had a chest pain, dyspnea (-), nausea (-), vomitting (-)
Defecation and urination are normal
History of Past Illness
History of chest pain (-)History of hypertension (-)History of Diabetes Mellitus (-)History of dyslipidemia (-)Family history of heart disease (-)History of smoking (+) about 1-2
packs a day for about 20 years.
Risk Factors
MODIFIABLE :• Hypertension (-) • Diabetes mellitus
(-)• Dyslipidemia (-)• Smoking (+)• Obesity (-)
NON-MODIFIABLE• Gender : man• Age : 52 years old • Personal history of CAD
(-)• Family history of CAD
(-)
PHYSICAL EXAMINATION
• General Status :
moderate-illness/well-nourished/composmentis
• Vital Sign :
BP = 130/90 mmHg
Pulse = 85 bpm, regular
RR = 22 bpm
Temperature = afebris
Regional Status
Head Examination Eyes : anemic -/-, icterus -/- Lip : cyanosis (-) Neck : lymphadenopathy (-), JVP R-1 cmH2O supineChest Examination Inspection : symmetric R=L, normochest Palpation : mass (-), tenderness (-), VF R=L Percussion : sonor Auscultation : vesicular breath sound, no additional
sound
Cardiac Examination Inspection : IC wasn’t visible Palpation : IC wasn’t palpable Percussion : normal heart size
Upper border : left 2nd ICS Lower border : left 5th ICS Right border : right parasternalis line Left border : left medioclavicular line
Auscultation : Regular of I/II heart sound, murmur (-)
Regional Status
Regional Status
Abdominal Examination Inspection : convecs and following breath movement Auscultation : peristaltic sound (+) , normal Palpation : liver and spleen unpalpable Percussion : tympani, ascites (-)
Extremities Oedema : pretibial -/- ; dorsum pedis -/- Cold extremities (-)
ELECTROCARDIOGRAPHY(4th September 2011 at emergency unit)
Interpretation
Sinus Rhythm, heart rate 76 bpmLeft Axis DeviationPathological Q wave at V1-V4Elevation of ST segment at I, aVL, V1-V5Normal T wave
Conclusion:ST elevation myocardial infarction on extensive anterior wall
LABORATORY FINDINGS
Haematological Routine
Examination
• WBC = 12,50. 103
• RBC = 4,94. 106
• HGB = 16,1• HCT = 46,3• PLT = 290. 103
Chemical Blood Examination and Cardiac enzymes
• GDS = 108• GOT/GPT =
31/37• CK = 222• CKMB = no
reagen• Trop-T = 0,13
WORKING DIAGNOSE
ST Elevation Myocardial Infarction extensive anterior wall
MANAGEMENT
O2 4-6 L/minuteIVFD NaCl 0,9% 10 drips per minuteAspirin (Aspilet) 180 mg (loading dose), then
continued once daily on the next dayClopidogrel (Plavix) 300 mg (loading dose), then
continued once daily on the next dayNitrat (Farsorbid) 5 mg (SL), then continued with
Farsorbid via SPNa Fondaparinux (Arixtra) 2,5 mg/24 hours/SCSimvastatin 20 mg 0-0-1Captopril 12,5 mg three times dailyLaxadyn syr. twice dailyThe patient must be catheterized
PLANNING
Enter the patient to CVCUMonitoring ECG everydayEchocardiographyCoronary Angiography
ECHOCARDIOGRAPHY
Interpretation
Conclusion:Systolic and dyastolic dysfunction of
left ventricle e.c. Coronary Artery Disease
Left Ventricle HypertrophyEF 36%
DISCUSSION
ST ELEVATIONMYOCARDIAL INFARCTION
INTRODUCTION
Acute myocardial infarction (AMI) is an irreversible necrosis of heart muscle due to prolonged ischemia, which is suddenly happened.
Acute myocardial infarction (AMI) is one of the most common diagnoses in hospitalized patients in industrialized countries.
PATHOPHYSIOLOGY
STEMI generally occurs when coronary blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis.
In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when condition favor thrombogenesis.
CLINICAL FEATURES
Deep and visceral chest pain > 20 minutes, similar to discomfort of angina pectoris but commonly occurs at rest, more severe, and lasts longer.
Feels like “heavy”, “squeezing”, “crushing”, “burning sensation”
Involves the central portion of chest and/or the epigastrium, radiates to the arm, abdomen, back, lower jaw, and neck.
It is often accompanied by weakness, sweating, nausea, vomiting, anxiety.
Not relieve with rest or nitrat
HOW TO DIAGNOSE…
No
Yes
Yes
No
Acute Myocardial Infarction
NSTEMI( Non ST-Elevation
Myocardial Infarction )
Unstable Angina
Signs of myocardial ischemia
↑ Biochemical cardiac markers ?
ECG
Lab
ST segmen elevation?
ADDITIONAL EXAMINATION (1)
Electrocardiogram It is begun with depression of ST-segment and
inverted of T-wave Then it is changed to elevation of ST-segment and
absence of R-wave until the presence of Q-wave
ADDITIONAL EXAMINATION (2)
Serum cardiac biomarkers Certain proteins are released from necrotic heart
muscle after STEMI Cardiac Troponin (cTnT and cTnI) are not normally
detectable in the blood of healthy individuals but may increase after STEMI to levels >20 times higher than the upper reference limit
Other serum cardiac biomarkers are Creatine phosphokinase (CK) and the MB isoenzyme of CK
MANAGEMENT
Fixing the chest pain and fearnesso Bed resto Dieto O2 2-4 lpm via nasal prongs or face masko Sublingual/oral/IV nitroglycerineo Antiplatelet: aspirin and clopidogrelo Morfin/petidineo Diazepam 2-5mg/8 hour
Stabilizing the hemodynamic (blood pressure and peripheral pulse control)o β-blockero Calcium channel blocker (CCB)o ACE-Inhibitor
Reperfusion of the myocardo Thrombolytic
THANK YOU
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