Acute Coronary Syndrome:

Unstable Angina Pectoris

Case report by:

Riyan Wirawan
I 11112052

Preceptor:
Letkol (CKM) dr. Prihati Pujowaskito, Sp. JP (K), MMRS
Cardiology Department Dustira District Hospital
Faculty of Medicine Tanjungpura University
2018
 Patient’s Identity
 Name : Mr. WS
 Sex : Male
 Age : 50 years old
 Religion : Moeslem
 Address : Perum Peruri, Sinabaya
Village
 MR : 548020
 Admission : 16 June 2018
 Anamnesis (Autoanamnesis)
 Chief Complaint: Chest Pain
 Patien suffered chest pain after running
 chest pain in a left side radiating from chest to back
 patients feel tightness and nausea
 Vomiting (-)
 the patient had a history of stenting in Gatot Subroto hospital
 History of diabetic (-)
 Physical Examination
BP = 130/90 mmHg PR = 78 bpm, reguler RR = 18 tpm T = 36.0 celcius
SpO2 = 96%

General appearance looked moderately ill GCS (15) E4 V5 M6 ; VAS Score : 5

Head Anemic (-) Icteric (-)

Neck JVP 5+2 cmH2O

Thorax Retraction (-), Ictus Cordis not seen.

Cor S1 S2 single, mur mur (-), gallop (-) extrasystole (-)

Pulmo Simetric, SF D = S Rh -/- Wh - /-

Abdomen Convex, Soefl, Hepar : Liver span 11 cm, spleen traube space tympani.
Tenderness (-)

Extremities Oedema ( -/-)

 Laboratorium Findings
June 16th 2018
Hemoglobin : 16,5 g/dl CKMB : 13 U/L
Eritrosit : 5,7 x 106/µl GDS : 85 mg/dl
Leukosit : 8,4 x 103/µl
Hematokrit : 48,0%
Trombosit : 213 x 103/µl
MCV : 84,8 fl
MCH : 29,2 pg
MCHC : 34,4 g/dl
RDW : 13,1 %
Ba/Eo/Sg N/Li/Mo:
0,7/9,1/57,6/125,8/6,8 %
Laboratorium Findings
June 17th 2018
Natrium (Na) : 140 mmol/L
Kalium : 3.80 mmol/L
Klorida : 105 mmol/L
Ureum : 22 m/dl
Creatinin : 1.0 mg/dl
Trigliserida : 344 mg/dl
LDL Cholestrol : 158 mg/dl
HBsAg : Non Reaktif
ECG June 16th 2018
ECG
 Rhytme : Sinus
 Freq : 68 bpm
 Axis : Left Axis Deviation (LAD)
 P wave : 0,08 s
 Interval P-R : 0, 020 s
 Q wave : Normal Q wave
 QRS wave : 0,08 s
 ST segment : isoelectric
 T wave : T inverted in V3-V6, 1, aVL
 QT interval : QTc: 0,36 s
 Abnormalities : QS pattern in lead V1-V4, QS
pattern in lead II, III, aVF
 Conclusion : Sinus Rhytm, LAD with Ischemic
Anterolateral, OMI anteroseptal,
OMI inferior
Diagnosis
 Clinical Diagnosis
 Acute Coronary Syndrome : Angina Pectoris
Unstable (ACS UAP)

 Anatomic Diagnosis
 Ischemic anterolatheral, OMI anteroseptal,
OMI inferior

 Etiologic Diagnosis
 Atherosclerosis
 Therapy
 Non medical:
 Total Bedrest
 Semifowler position
 Low salt diet

 Oxygen 3-4 lpm

 Pharmacology
 Enoxaparin SC inj. Twice daily
 Clopidogrel 300 mg oral loading dose
Therapy
 ISDN 5 mg oral/12 hours
 Aspirin 160 mg oral loading dose
 Ramipril 2,5 mg oral once daily
 Atorvastatin 20 mg oral twice daily
 Warfarin 2 mg oral once daily
Therapy
 Long-term Therapy
 Lifestyle interventions and risk factor
control
 DAPT  Aspirin 75-100 mg once daily
+ Clopidogrel 75 mg once daily
 Bisoprolol 2,5 mg once daily
 Atorvastatin 40 mg 0-0-1
 Sublingual ISDN 5 mg prn
 Ramipril 2,5 mg once daily
Prognosis
 Quo ad vitam : dubia ad malam
 Quo ad sanactionam : dubia ad malam
 Quo ad functionam : dubia ad malam