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    Lapkas Kardio Nstemi Af

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    Ridho Mochine Fisciensa
    The document summarizes a case report of a 63-year-old male patient presenting with acute coronary syndrome including non-ST elevation myocardial infarction and atrial fibrillation with rapid ventricular response. The patient's history, examination findings, lab and ECG results are presented. Diagnoses of old inferior myocardial infarction and atherosclerosis are made. The patient is managed medically and considered for primary percutaneous coronary intervention. The prognosis is guarded.

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    Lapkas Kardio Nstemi Af

    Uploaded by

    Ridho Mochine Fisciensa
    30 views14 pages
    The document summarizes a case report of a 63-year-old male patient presenting with acute coronary syndrome including non-ST elevation myocardial infarction and atrial fibrillation with rapid ventricular response. The patient's history, examination findings, lab and ECG results are presented. Diagnoses of old inferior myocardial infarction and atherosclerosis are made. The patient is managed medically and considered for primary percutaneous coronary intervention. The prognosis is guarded.

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    LAPKAS KARDIO NSTEMI AF

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    The document summarizes a case report of a 63-year-old male patient presenting with acute coronary syndrome including non-ST elevation myocardial infarction and atrial fibrillation with rapid ventricular response. The patient's history, examination findings, lab and ECG results are presented. Diagnoses of old inferior myocardial infarction and atherosclerosis are made. The patient is managed medically and considered for primary percutaneous coronary intervention. The prognosis is guarded.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    30 views14 pages

    Lapkas Kardio Nstemi Af

    Uploaded by

    Ridho Mochine Fisciensa
    The document summarizes a case report of a 63-year-old male patient presenting with acute coronary syndrome including non-ST elevation myocardial infarction and atrial fibrillation with rapid ventricular response. The patient's history, examination findings, lab and ECG results are presented. Diagnoses of old inferior myocardial infarction and atherosclerosis are made. The patient is managed medically and considered for primary percutaneous coronary intervention. The prognosis is guarded.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 14

    ACUTE CORONARY SYNDROME

    NON-ST ELEVATION MIOCARD INFARCTION


    ATRIAL FIBRILLATION
    RAPID VENTRICULAR RESPONSE

    a Case Report
    by
    Ridhallah

    Preceptor:
    Kolonel dr. Prihati Pujowaskito, Sp. JP (K), MMRS

    Cardiology Department
    Dustira Educational Hospital Cimahi
    2018
    Patient’s Identity
    • Name : Mr. W
    • Gender : Male
    • Age : 63 Years old
    • Address : Pasir Kumeli Cimahi
    • Occupation : entrepreneur
    • Religion : Protestan
    • Admission date : Sept 02 nd 2018
    Chief Complain
    Chest pain
    History of Present illness
    • Patient attended to Emergency department complaining of
    chest pain since 3 days ago and getting heavy since 4
    hours before he goes to the hospital.
    • Chest pain describes as feeling as if something heavy
    were put on his chest or squeezing his chest.
    • Chest pain was radiating to the back. It was persistent
    about 20 minutes.
    • Chest pain also followed by diaphoresis, pain in the
    epigastrium, nausea, and palpitation.
    Past Illness History
    • History of hipertension
    • No history of diabetes mellitus and heart
    disease, or astma
    Family History

    • History of hypertension in family (+)


    • History of diabetes melitus (-)
    • History of heart disease in family (+)
    • History of stroke in family (-)

    Personal and social history

    • Patient not a smoker.


    • Alcohol (-)
    • Daily diet is high fat, enough carbohydrat and protein
    Physical Examination

    General Looked Moderate


    Appearance:

    Weight : 68 kg
    Nutritional Height : 168 cm
    status:
    BMI : 23,6 kg / m2
    Conclusion : Normal

    6
    Physical Examination

    7
    Laboratory Findings
    28/10/2017
    Hb : 15,9 g/dl MCV : 79,2 fl
    Erythrocytes : 5,9 x 106 /uL MCH : 26,9 pg
    Leukocytes : 7.800 /uL MCHC : 33,9 g/dl
    Ht : 46,9 % RDW : 15,4%
    Ba/Eo/Sg/Li/M:
    Platelets : 323.000/ uL 0,6/0,1/70,5/20,2/8,6
    Nonfasting Blood Glucose:
    Ureum : 22 mg/dl 103 mg/dl
    Creatinin : 0,8 mg/dl CKMB: 27 U/L
    Electrocardiography 02/09/2018

    • Rhythm: atrial • PR Interval : -


    • Frequency: 100-150 bpm ireguler • QRS complex : 0,04 s
    • Frontal axis : normoaxis) • Abnormality: No p wave with R-R interval irreguler
    Patologic Q wave in lead III, aVF
    • P Wave : No P wave
    Conclusion : Atrial fibrilation with moderate ventricular
    response, and old miokard infarction in inferior
    Diagnosis
    • Clinical Diagnosis : Acute Coronary Syndrome
    NSTEMI, Atrial Fibrillation
    Rapid Ventricular Response
    • Anatomical Diagnosis : Old miokard infarction
    Inferior
    • Etiological Diagnosis : Atherosclerosis
    Management
    In Emergency Departement:
    Bed Rest
    O2 via nasal canule 4 lpm (If SpO2 < 90%)
    •IVFD RL 500 cc/ 24 hours
    •PO Loading CPG 300 mg (4 tab)
    •PO ISDN 5 mg (can repeat maks 3 times)
    •PO Aspilet 160 mg ( 2 tab)
    •Digoxin (1X0,25 mg)
    •Inj. Enoxaparin 2 x 0,6 cc
    •PO Atorvastatin 1X20 mg
    Reperfusion Management
    • Ivfd RL 500 cc/24 jam
    • Inj. Enoxaparin 2x0,6cc
    • PO. ISDN 2x5 mg SL
    • PO. Aspilet 1x80 mg
    • PO. Valsartan 1x80 mg
    • PO. Atorvastatin 0-0-20 mg
    • PO. Clopidogrel 1x75 mg
    • PO. Digoxin 1x0,25 mg
    • Pro Primary PCI
    Prognosis

    • Quo ad vitam : dubia ad malam


    • Quo ad functionam : dubia ad malam
    • Quo ad Sanactionam : dubia ad malam

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