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PATIENT IDENTITY
Name
: Mr. A
Medical Record : 375155
Age
: 54 years old
Address : Bau-bau
HISTORY TAKING
HISTORY TAKING
-
RISK FACTOR
He
PHYSICAL EXAMINATION
Vital Sign :
Blood pressure
: 130/90 mmHg
Pulse
: 84 x/min
Inspiratory rate
: 28 x/min
Body temperature : 36,5oC
Inspection
: Symetric
Palpation
: no mass, no tenderness
Percussion
: Sonor
Auscultation : Breath Sound : vesikular
Additional sound :Ronchi +/+ basal, Wheezing -/-
Head Examination :
Thoracal Examination :
PHYSICAL EXAMINATION
Heart
Examination :
Inspection : ictus cordis was no visible
Palpation : ictus cordis was no palpable
Percussion : widening of heart size
Auscultation
: regular of I/II Heart Sound, no murmur
Stomach
Examination :
Inspection : normal
Palpation : no mass, tenderness on regioepigastrium
Percussion : tympani, mild acites (+)
Auscultation : peristaltic sound (+), normal
Extremity
ADDITIONAL EXAMINATION
Complete blood
WBC
HGB
RBC
PLT
HCT
Blood electrolyte
Sodium
Potassium
Chloride
Heart enzim
CK
CKMB
Troponin-T
: 9,3 x 10 /mm
: 12 g/dl
: 4,44 x 106 /mm3
: 206 x 103 /mm3
: 38,4 %
3
: 125 mmol/l
: 2,7 mmol/l
: 93 mmol/l
: 59
: 33 U/l
: < 0,1 ng/ml
Blood chemistry
Random blood sugar
: 242 mg/dl
Fasting blood sugar : 131 mg/dl
SGOT
: 89 u/l
SGPT
: 1,7 u/l
Cholesterol total
: 201 mg/dl
Cholesterol HDL
: 10 mg/dl
Cholesterol LDL
: 71 mg/dl
Triglyseride
: 203 mg/dl
Protein total : 6,5
Albumin : 2,5
Globulin : 2,8
Ureum
: 34
Creatinin : 0,6
Uric acid : 8.0
ECG :
-Sinus rhytme
-Lateral wall ischemia
-LAD
ADDITIONAL EXAMINATION
Chest x-ray :
Cardiomegaly with
sign of pulmonal
edema
ADDITIONAL EXAMINATION
Echocardiography :
- CHF
-CAD
- PH
SUGGESTION ADDITIONAL
EXAMINATION
Coronary
angiography
DIAGNOSIS
CHF NYHA III-IV e.c CAD
DM type 2
MANAGEMENT
MANAGEMENT...
DISCUSSION
Pathogenesis:
Myocardial O2 supply
Narrow vessel because
flaque
Forming of trombus because
trombosite agregation
Spasme coronaria artery
Myocardial O2 requirements
Activity increase
RISK FACTORS
RISK FACTORS
Risk
CLINIC
SYNDROM OF CAD :
Angina Pectoris
Infark Miokard
Non-Q wave
Q wave
When
CHF considered present if two major or one major plus two minor criteria
are fulfilled
Major Criteria
Minor criteria
Manifestations of LHF
Forward effects
Brain
restlessness,
anxiety, generalized
fatigue.
Kidney
low urine output with
subsequent fluid
retention, high
afterload due to RAA
cascade activation,
kidney failure.
Backward effects
Dyspneu
cough
Manifestations of RHF
Forward effects
Backward effects
TREATMENTS
MANAGING PRELOAD
MANAGING CONTRACTILITY
MANAGING AFTERLOAD
NEUROHORMONAL
MODULATION