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PATIENT IDENTITY
Medical Name Gender Age Address Date
Record
of admission
HISTORY TAKING
HISTORY TAKING
History of chest pain (+) about 3 weeks ago, relieved by rest History of hypertension (+) since 10 years ago No history of heart disease, there is a family history of heart disease, his brother History of diabetes mellitus (+) No history of dyslipidemia No history of asthma History of epigastric pain (+) since 3 years ago
Life style :
History of smoking ( +) 3 packs / day History of drinking alcohol (+) since 10 years ago
RISK FACTOR
Non Modifiable Gender: Male Age: 49 yo
Modifiable
Hypertension (+)
DM (+) Obesity (+)
Smoking
PHYSICAL EXAMINATION
BP HR RR T BW H
PHYSICAL EXAMINATION
Head Examination
: Anemic -/-, Icterus -/: Cyanosis (-) : Lymphadenopathy (-), JVP R+1 cmH2O
Thorax Examination
: Symmetrical R=L, normochest : Mass (-), tenderness (-), VF R=L : Sonor : Bronchovesicular Ronchi +/+, Wheezing -/-
PHYSICAL EXAMINATION
Cardiac
Insp. Palp.
Examination
: IC wasnt visible : IC wasnt palpable : Dull
: Right parasternalis line : 2 Fingers after midclavicularis line
Perc.
Ausc.
PHYSICAL EXAMINATION
Abdominal Examination
: Flat and following breath movement : Peristaltic sound (+), normal : Liver and spleen is unpalpable : Tympani (+), ascites (-)
Extremities
ELECTROCARDIOGRAPHY ECG
Interpretation
Sinus Rhythm Heart Rate :89x/I P Wave : 0.08 PR interval :0.12 QRS complex
:0.08 Axis : normoaxis ST elevated at V1-V6, AVL Conclusion: Myocard Infarct Extensive Anterior
LABORATORY EXAMINATION
WBC
: 15.80 HB : 16,7 gr/dl PLT : 288.000 HCT : 45,6 % GDS : 183 mg/dl Ureum : 22 mg/dl Creatinin : 0,9 mg/d
: 2708 U/L : 200 U/L : 0,89 : 146mmol/l : 4,19mmol/ : 105mmol/l : 118 U/L : 39 U/L
Echocardiography
LV
systolic function & diastolik decreased left ventricle CEF 38% Akinetic septal & apilkal, hipokinetik lateral
DIAGNOSIS
-
INITIAL MANAGEMENT
Bed rest O2 2-4 LPM (via nasal canule) Heart Diet IVFD NaCl 0,9% loading 500 cc/24 hours 140/90 mmHg Anti Platelet Aggregation ASA (Aspilet) loading dose 160 mg (2 x 80 mg) maintenance 1-0-0 Clopidogrel (Plavix) loading dose 300 mg (4 x 75 mg) maintenance 0-1-0 Anti cholesterol HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) Anti coagulant Low Molecule Weight Heparin(Fondaparinux(Arixtra)) 2,5 mg/24 jam/SC Diuretiic Furosemide 40 mg 2x1 Anxiolytic Benzodiazepin (Alprazolam 1 x 0,5 mg) Laxative Laxadin syrup 1 x 2 cth Anti hypertension Ace-inhibitor (Captopril) 3x12,5 mg
PLANNING
Echocardiography Coronary
angiography
1 point
1 point
3 point typical chest pain 2 point atypical chest pain 1 point or none non cardiac chest pain
DEFINITION
Acute Coronary Syndrome (ACS) is a term for situations where the blood supplied to the
CLASSIFICATION
PATHOPHYSIOLOGY
Vulnerable Plaque Thrombosis Vasospasme Plaque disruption and thrombosis that result in complete coronary artery occlusion leads to transmural ischemia and necrosis, the hallmark of ST-segment elevation myocardial infarction (STEMI)
PATHOGENESIS
Lipid transport disorder Inflamation Plaque deposition
Stable plaque
Thrombus
Erosion
Plaque rupture
Acute coronary syndrome: Unstable angina Myocardial infarction : - Non Q waves - Q waves
Thrombosis
RISK FACTOR
Non- Modifiable
Gender and Age Men, increased risk after age 45 Women, increased risk after age 55 Family History Heart disease diagnosed before age 55 in father or brother
Modifiable
Smoking Hypertension Diabetes Mellitus Dyslipidemia Obesity
DIAGNOSIS OF ACS
CLINICAL FEATURES
Substernal chest pain / chest discomfort radiated to the left arm, shoulder, neck, jaw. Penetrated to the back. The chest discomfort may also be described as a dull pain ,pressure, squeezing or crushing sensation or burning sensation Duration more than 20 minutes. more intense and persistent.
SGOT
LDH
Myoglobin
DIAGNOSIS
INITIAL MANAGEMENT
Fixing the chest pain and fearness Bed rest Diet O2 2-4 lpm Nitroglycerin: 0,4 mg SL tablets every 3-5 minutes up to 3 times; if effect is not sustained, can continue with an IV drip of 50 mg in 250 ml dextrose 5% Antiplatelet : Aspirin: 162-325 mg chewed immediately and 81-162 mg continued indefinetely Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least 14 days and up to 12 months. Morphine 2-5 mg IV every 5-30 minutes Pethidine 12,5 mg/IV Diazepam 2-5mg/8 hour Stabilizing the hemodynamic (blood pressure and pheripheral pulse control) -blocker Calcium channel blocker (CCB) ACE-Inhibitor Reperfusion of the myocard Thrombolytic: streptokinase 1,5 million units/IV
IV
60 80
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