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C11109399
Supervisor : Prof.Dr.dr.Ali Aspar, M, Sp.PD, Sp.JP, FIHA,
FAsCC, FINASIM, FICA
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2014
PATIENTS IDENTITY
Name
: Mrs. K
Gender
: Female
Age
: 45 years old
RM
: 624731
Date of Admission : August
12nd, 14
History Taking
Chief Complaint : Chest pain
Guided Anamnesis:
Symptoms felt since 3 hours before admitted to
hospital. Symptoms was triggered by activity, it
was felt like heavy pressed at epigastric area and
it radiates to the left arm. The duration was >20
min. it wasnt relieved by consuming ISDN 5mg/SL
and rest. It usually accompanied by cold sweating.
History of chest pain before (+) about 1 year ago
and in hospitalized. History in angiography and
advised to coronary stent. Regular medical
treatment history (+).
Modifiable
Hypertension
Non
modifiable
Female 45 years
old
History of chest
pain 1year ago
Clinical Examination
GENERAL STATE
Moderate illness/well-nourished/conscious
VITAL SIGN
- Blood pressure
: 130/80 mmHg
- Pulse
: 108 beats/min
- Breathing
: 20 times/min
-
Head Examination
Eyes : anemia -/-, icterus -/-, oedema
palpebra -/
Chest Examination
Inspection
: symmetric R=L, normochest
Palpation : mass (-), tenderness (-),
fremitus right = left
Percussion
: sonor left and right
Auscultation : breath sound : vesicular
additional sound : ronchi -/-
vocal
wheezing -/-
Cardiac Examination
Inspection
: IC is not visible
Palpation
: IC is not palpable
Percussion
: Right heart border in left
parasternal line, left
heart
border in left
midclavicular line
Auscultation : Regular S1/S2 heart sound,
murmur (-)
Abdominal Examination
Inspection : Flat and follows
breath
movement
Auscultation : Peristaltic sound (+)
Palpation : Liver and spleen not
palpable
Percussion : Timpany (+)
Extremities
- Oedema : Pretibial -/-
Rhythm
: sinus rhytm
QRS rate
: HR 107 bpm
P wave
: 0.08 sec
PR interval
: 0.16 sec
QRS complex : 0.08 sec
Axis
: Normoaxis
ST segment
: isoelektric
Conclusion: Sinus Tachycardi, normoaxis
TEST
RESULT
NORMAL VALUE
WBC
4,0-10,0 x 103 /l
RBC
4,0-6,0 x 106 /l
Hb
14,1mg/dl
13,0-17,0 g/dl
Hct
40,1 %
40,0-54,0 %
GDS
105 mg/dl
140 mg/dl
Ureum
31 mg/dl
10-50 mg/dl
Creatinin
0,5 mg/dl
M(<1,3);F(<1,1)
mg/dl
PLT
150-500 x 103 /l
TEST
RESULT
NORMAL VALUE
CK
90 U/L
L(<190) P (<167)
Troponin T
0.01
0.05
SGOT
32 mg/dl
<38 U/l
SGPT
53 mg/dl
<41 U/l
Total Cholesterol
342 mg/dl
200 mg/dl
HDL
51 mg/dl
M(>55);F(>65) mg/dl
LDL
157 mg/dl
<130 mg/dl
TG
267 mg/dl
200 mg/dl
Uric Acid
4.3 mg/dl
2,4-5,7 mg/dl
CHEST X-RAY PA
Bed rest
O2 2-4 LPM via Nasal Canule
IVFD NaCl 0,9% 12 dpm
Nitrate : ISDN Fasorbid (10mg/cc) 2mg/hr/SP
Anti-platelet aggregation :
Aspilet 80 mg 1x2
Clopidogrel 75 mg 1x4
Anti-coagulant : Fondaparinux 2,5mg/24hrs/SC
Anti-Hypertension : Captopril 25mg 1-1-1
Statin : Simvastatin 20mg (0-0-1)
Anti-anxiety : Alprazolam 0.5 mg (0-0-1)
Laxative: Laxadyne syr 0-0-2
Plaque
Fissure or
Rupture
Platelet
Adhesion
Platelet
Activation
Platelet
Aggregation
Thrombotic
Occlusion
Imbala
nce
Non-modifiable
Non-modifiable
Age
Age
Gender
Gender
Family History of Hearth
Disease
Family History of Hearth
Disease
Modifiable
Modifiable
Smoking
Dislipidemia
Smoking
Dislipidemia
Hypertension
Hypertension
Diabetes mellitus
Diabetes
mellitus
Lack of exercise
Lack
of exercise
Obesity
Obesity
Usually retrosternal
location, radiating to left
chest, left arm, can be
epigastric
Dyspnea
Diaphoresis
Palpitations
Nausea/vomiting
DIAGNOSIS
ECG
Yes
No
Lab
Yes
No
Unstable Angina
Therapeutic Goals
33