CASE REPORT CARDIOLOGY DEPARTMENT

Presented by:
Nor Farhana Bt Omar C11109870
Supervisor:
Dr. dr. Khalid Saleh, SpPD-KKV, FINASIM
PRESENTED IN THE CONTEXT OF THE CLINICAL DUTIES
CARDIOVASCULAR DEPARTMENT
MEDICAL FACULTY
HASANUDDIN UNIVERSITY
2014

PATIENTS IDENTITY

NAME
AGE
GENDER
MR
Day of Admission

:
:
:
:
:

Mr. M
52 years old
Male
247078
10/06/2014

HISTORY TAKING

CHIEF COMPLAINT: Chest pain

Structural Anamnesis:
It was felt 1 day before admitted to the hospital.
The pain was felt on the left side of the chest with
the characteristics of dull heavy feeling of the chest,
duration of pain was > 30 minutes, radiates to the
left arm and to the back. The pain exacerbates with
exercises and did not lessen with rest or medication.
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 2 years ago with
uncontrolled therapy.
History of dyslipidemia is denied.
History of hyperuricemia (-)
History of smoking (+) since 20 years ago but
stopped since admitted to the hospital. 3 packages
per day.
History of cardiovascular disease (-)
History of cardiovascular disease in family (-)

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

: 160/100 mmHg
: 68 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, following breath 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
(ECG)

ECG Interpretation
Rhythm
: Sinus Rhythm
HR / QRS rate
: 54 times/min
Axis
: Normoaxis
Regularity
: Regular
P wave
: 0,04 s
PR interval
: 0,12 s
QRS complex
: 3 small squares (0,12 s)
ST segment
: ST Elevation at V3-V4
Conclusion
: Sinus rhythm, HR 54 times/min,
STEMI extensive anterior wall

LABORATORY FINDINGS 10 /6/2014

WBC

9.76 x 10/uL

GOT

46 U/L

RBC

4.65 x 10/uL

GPT

45 U/L

HB

14.0 g/dL

Albumin

3.8 gr/dL

HCT

42.0 %

Total Cholesterol

250 mg/dL

PLT

195 x 10/uL

LDL Cholesterol

177 mg/dL

PT

13.2 control 10.8 sec

Triglyceride

75 mg/dL

APTT

25.8 control 27.6 sec

CK

538 U/L

INR

1.095

CK-MB

44 U/L

GDS

140 mg/dL

Troponin T

0.21

Ur

27 mg/dL

Uric Acid

4.9 mg/dL

Cr

0.9 mg/dL

Electrolytes (Na, K, Cl) 140, 3.45, 110 mmol

CHEST X-RAYS 10/6/2014

Bronchodilated lungs.
Enlargement of the cardiac
with CTI 15/22=0.68, concave
cardiac waist , elevated apex,
dilated, elongated and
calcification of aorta.
Both sinus and diaphragm in
good conditions.
Bones are intact.

Conclusion:
Cardiomegaly with signs of
congestive lungs.
Dilation, elongation and
atherosclerosis of aorta.

ECHOCARDIOGRAM
11/6/2014

Description of Wall Motion, Masses,

Valves, Pericardium

Decrease systolic function of LV, EF 34 %.

Dilated LA, LV.
Hypokinetic anterior, septal,
anterolateral.
LVH (+)
Good RV function, TAPSE 2.0 cm.
Heart valves:
Mitral: Mild MR.
Aorta: 3 cusps, calcification (-), mild
AR.
Tricuspid: Good function and
movement.
Pulmonary: Good function and
movement.
E/A<1

Conclusion:
Systolic and
diastolic
dysfunction,
LV EF 34 %.
Dilation of LV.
Hypokinetic
anterior,
septal,
anterolateral.
LVH.
Mild MR, Mild
AR.

CORONARY ANGIOGRAPHY
16/6/2014

Cannulation of LCA and RCA angiography shows:

LM

: Normal
LAD
: 90 % stenosis after D2 branch.
LCX
: Proximal total occlusion, distal filled from
ipsilateral collateral.
RCA
: Total occlusion at proximal and branches
of PDA and PL (big) filled from LCA.

Conclusion: Severe 3 VD.

Suggestions: 1. CABG
2. PCI LAD

WORKING DIAGNOSIS
ANTERIOR WALL STEMI
ONSET > 12 Hours KILLIP II
GRADE II HYPERTENSION

MANAGEMENT

O2 2 -4 Lpm

Bed rest
IVFD NaCl 0.9% 10 tpm
Antiplatelet
---- Aspilet 80 mg 0-1-0
Antiplatelet
---- Plavix 75 mg 0-0-1
Loop diuretic
---- Furosemide 1 amp/12h/IV
Nitrate
---- Cedocard 1 mg/hour/SP
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

DIAGNOSIS

Oxford Handbook of Clinical Medicine 6 th Edition

Diagnosis of ACS

CLINICAL MANIFESTATIONS

Diagnostic ECG Changes

Acute Coronary Syndromes. Third Edition Edited by Eric J. Topol The Cleveland Clinic Foundation
Cleveland, Ohio, U.S.A. Revised and Expanded

Serum Cardiac Marker

Elevation

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

PROGNOSIS
KILLIP CLASSIFICATION
Class

Description

Mortality Rate
(%)

No clinical signs of heart failure

II

Rales or crackles in the lungs, an S3,

and elevated jugular venous
pressure

III

Acute pulmonary edema

30 - 40

IV

Cardiogenic shock or hypotension

(systolic BP < 90 mmHg), and
evidence of peripheral
vasoconstriction

60 80

17

Acute coronary syndrome, 3rd ed.Revised and expanded

TIMI (thrombo;ysis in myocardiac infarction)

PROGNOSIS
Risk Factor

Score

Age > 65 years old

>/= 75

2
3

History of
angina/hipertension/DM

Total
Score

Risk of
Death in 30
days

0.8%

1.6%

2.2%

Systolic BP <100

4.4%

Heart rate >100

7.3%

Killip II-IV

12.4%

Weight >67 kg

16.1%

Anterior MI or LBBB

23.4%

Delay treatment >4 hours

26.8%

9-14

35.9%