anterior septal stemi with onset.pptx

8/14/2019 ANTERIOR SEPTAL STEMI WITH ONSET.pptx

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Presented by:Amelya Matasik C11108175

Supervisor:dr. Pendrik Tandean, Sp. PD-KKV, FINASIM

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK

BAGIAN KARDIOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN

MAKASSAR

2013

CASE REPORT CARDIOLOGY DEPARTMENT


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NAME : Mr. M AGE : 62 years old

GENDER : Male MR : 629171 Day of Admission : 27/9/2013


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Chief Complain :Chest PainStructural Anamnesis:

Occurred since about 7 hours before admitted to thehospital. On theleft sidethe chest pain feels dull heavy pain,

it seems to radiates to the back. It does not radiate to theshoulder/arm. Chest pain last for30 minutes.The pain is notlessen at rest or with medication.Patient had experienced chest pain for a year long.However,patient did not check it to the hospital, because at that time

the pain it did not disturb his everyday activities and lessenat rest.The chest pain accompanied with shortness of breath, coldsweat (+), fever (-), cough (-), nausea (+), vomit (+), epigastricpain (-). Defecation and urination normal.


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History of cigarette smoking (-) History of alcohol consumption(-)

History of hypertension (+) , since 3 years agowith uncontrolled therapy.

History of Amlodipin consumption 5 mg 1x1

History of Diabetes mellitus (-)

History of heart disease is denied


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General status: Moderate Ilness/ Overweight/Conscious

Body Weight :70 kg

Body Height :170 cm

Body Mass Index : 24,2 kg/m2

Vital Status

Blood Pressure : 150/100 mmHg Heart Rate : 88 bpm

Respiratory Rate : 20

Body Temperature : 36,7 C


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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 :

Breath Sounds : Vesicular

Adventitious breath sound : Ronchi -/-, wheezing -/-


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Cardiac Examination

Inspection : Heart apex was not visible

Palpation : Heart apex was not palpable

Percussion : Dull, left heart border leftmidclavicular line ICS V.

Auscultation : Heart Sounds : S I/II regular,

murmur (-) gallop(-)


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Abdominal Examination

Inspection : Flat, following breath movement

Auscultation : Peristaltic sound (+), normal

Palpation : No mass, no tenderness, nopalpable liver or spleen.

Percussion : Tympani (+)

Extremities Examination

Pretibial edema -/-

Dorsal pedis edema -/-


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ECG :Sinus rhythm,QRS rate 83 bites/minute, north westaxis, PR interval 0,16 s,P wave 0,08 s, QRS

complex 0,08 s, Qpatologis III, aVF, V1-V3ST segment elevationV1-V5

Conclusion : sinus

rhythm, HR 83bite/minute, wholeanterior acute myocardinfraction , old myocardinfraction inferior


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ECG :Sinus rhythm, QRSrate 93 bites/ minute,right axis devilation, PRinterval 0,12 s, P wave0,08 s, QRS comlex 0,08s, Q patologis in III, aVF,V1-V3ST segment elevation inV1-V5

Conclusion : sinus

rhythm, HR 93bite/minute, wholeanterior acute myocardinfraction , old myocardinfraction inferior


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Test Result Normal value

WBC 9,05 x 103/ul 4.0 10.0 x 103

RBC 4.86 x 106/l 4.0 6.0 x 106

HGB 15.0 gr/dl 12 16

HCT 44,6 % 37 48

PLT 141 x 103

/l 150 400 x 103

Complete blood count


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GDS 141 mg/dl


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CK 211U/L


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Cloudy parahilar accompaniedwith cardiovascular suprahilardilatation on both lungs

There is no specific activeprocess seen on both lungs

Cor CTI widen 0,57 cm, aortadilated and calcified Both sinuses and diaphragma in

good condition Bones intact

Impression:Cardiomegaly with signs ofPulmonary edemadilatation et atherosclerosisaorta


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1. ST elevation myocardial infarction (STEMI)whole anterior onset >6 hours KILLIP I,

2. Old myocard infraction inferior3. Grade I hypertension


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O22 -4 Lpm IVFD NaCl 0,9% 10 drops/min Aspilet 80 mg 0-1-0 Aspirin (Antiplatelet)

Plavix 75 mg 0-0-1

Clopidogrel(Antiplatelet) Injection ISDN 0,5 mg/hours/SPNitrat Captopril 25 mg 1-1-1 ACE-Inhibitor Simvastatin 20 mg 0-0-1 Statin(Anticholesterol) Alprazolam 0,5 mg 0-0-1 Antianxietas Laxadyn syr 0-0-2c


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Echocardiography


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ST ELEVATION MYOCARDIAL

INFARCTION


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Myocardial infarction (MI) rapid development ofmyocardial necrosis causedby a critical imbalancebetween the oxygen supplyand demand of themyocardium.

This usually results fromplaque rupture withthrombus formation in a

coronary vessels, resulting inan acute reduction of bloodsupply to a portion of themyocardium.


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Occurs when coronaryblood flow decreasesabruptly after athrombotic occlusion

of a coronary arterypreviously affected byatherosclerosis.

In most cases,infarction occurs whenan atheroscleroticplaque fissures,ruptures, or ulcerates.


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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

Heart disease diagnosed before

age 65 in mother or sister

MODIFIABLE

Smoking

Hypertension

Diabetis Mellitus

Dyslipidemia

Obesity

Lack of physical activity


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Substernal chest pain / chest discomfort radiated tothe left arm, shoulder, neck, jaw. Penetrated to theback.

The chest discomfort may also be described as a dullpain ,pressure, squeezing or crushing sensation orburning sensation

Duration more than 20 minutes. more intense andpersistent.

Not fully relieved by rest or nitroglycerine Often accompanied by systemic symptoms: nausea,

vomiting, shortness of breath, palpitation, fatigue,cold sweat, light headedness


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1. Clinical history of ischemic type chest painlasting >20 minutes

2. Changes in serial ECG tracings3. Rise and fall of serum cardiac biomarkers

such as creatinine kinase-MB fraction andtroponin


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ST segment elevationover area of damage

ST depression in leads

opposite infarction Pathological Q waves Reduced R waves

Inverted T waves


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Cardiac enzymebiomarker

CK

CK-MB

Troponin T and I


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o

Yes

Yeso

Acute Myocardial Infarction(STEMI)

NSTEMI( Non ST-Elevation

Myocardial Infarction )

Unstable

Angina

Signs of myocardialischemia

Biochemical cardiac markers ?

ECG

Lab

ST segmen elevation ?


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Managing chest pain and anxietyo Bed resto Dieto O22-4 lpmo Nitrate sublingual/oral/IVo Antiplatelet: aspirin and clopidogrelo Morphine/ pethidine

Stabilizing hemodynamic (blood pressure and peripheral pulse control)

o

-blockero Calcium channel blocker (CCB)o ACE-Inhibitor

Reperfusion of the myocardiumo Thrombolytic


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Pericarditis Arrhythmia

Acute mitral regurgitation Ventricular septal rupture Cardiogenic shock


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Total Score Risk of Death in 30 days

0 0.8%

1 1.6%

2 2.2%

3 4.4%

4 7.3%

5 12.4%

6 16.1%

7 23.4%

8 26.8%

9-16 35.9%


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Class Description Mortality Rate (%)I no clinical signs of heart failure 6II

rales or crackles in the lungs, anS3, and elevated jugular venouspressure

17

III acute pulmonary edema 30 - 40IV

cardiogenic shock orhypotension (systolic BP < 90mmHg), and evidence ofperipheral vasoconstriction

60 80


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THANK YOU

anterior septal stemi with onset.pptx

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