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Supervisor:

Dr. Muzakkir Amir, Sp.JP, FIHA,FICA

PRESENTED IN THE CONTEXT OF CLERKSHIPCARDIOVASCULAR DEPARTMENT

MEDICAL FACULTYHASANUDDIN UNIVERSITY

2013

Presented by:

Nishalani Elangovan C11108759

CASE REPORT CARDIOLOGY DEPARTMENT

PATIENT’S IDENTITY

Name : Mr. A Age : 63 years

old Gender : Male MR : 600089 Day of Admission : 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/ ConsciousNutritional Status: Normal (BMI: kg/m²)Weight : 60 kg BMI: 23.4 kg/m2

Height : 160 cm

Vital Signs:Blood Pressure : 140/90 mmHgPulse Rate : 80 bpmRespiratory Rate : 20 bpmTemperature : 36.7 0C

Head and Neck Examinations:Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-) Lip : Cyanosis (-)Neck : JVP R +2 cmH₂O

Chest ExaminationInspection : 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 : Heart apex was not

visible – Palpation : Heart apex was not

palpable – Percussion : 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 ExaminationInspection : Flat, follows breathing

movementAuscultation : Peristaltic sound (+), normalPalpation : No mass, no tenderness, no

palpable liver or spleen.Percussion : Tympani (+)

Extremities ExaminationPretibial 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-V3Conclusion : Sinus rhythm, HR 75 bpm,

normoaxis, OMI inferior.

LABORATORY FINDINGS

WBC 11.35 x 10³/uL GOT 44 U/L

RBC 4.41 x 10⁶/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 10³/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 : NormalLAD : Diffuse stenosis prox-distal, small

vessel, 80 % stenosis after D1, 75-80% stenosis after D2

LCX : Proximal stenosis 80-90%, small vesselRCA : Proximal total occlusion, distal filled

from LCX Conclusion: CAD 3 VD, small vessel Suggestions: Conservative

WORKING DIAGNOSIS

NSTEMIHYPERTENSION 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


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

Non-Modifiable Smoking

Hypertension

Diabetes Mellitus

Dyslipidemia

Obesity

Lack of physical

activity

Modifiable

RISK FACTORS

DIAGNOSIS

Oxford Handbook of Clinical Medicine 6th 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

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Documents

right chest

left heart border

right heart border

family history

history of hypertension

history of dyslipidemia

history of hyperuricemia

history of smoking