MODUL 2 - CHEST

DISCOMFORT
GROUP 14:
PRIDINA SYADIRA : 110 2011 0006
SITI ABDILLAH MULIADI : 110 2014 0015
AKHMAD FADHIEL NOOR : 110 2014 0033
A.EKA OKTAVIANA B. PUTRI: 110 2014 0049
PRAMULIANSYAH HAQ : 110 2014 0053
ALIFA FAWZIA : 110 2014 0082
NURRAHMAH KADIR : 110 2014 0102
M. RHEZA RIVALDI SALAM : 110 2014 0114
SITI ADANI AYUNDI : 110 2014 0098
MUH. NUR ANSHARI SYAKIR : 110 2014 0150

MEDICAL FACULTY MUSLIM UNIVERSITY OF INDONESIA

MAKASSAR
2016
 Case 2
male 71 years, came to the clinic with complaints of
discomfort in the chest accompanied by a feeling hard to
breathe during the last 3 months, especially when climbing
stairs. patients with a history of smoking 30 cigarettes per
day. a family history of father died of a heart attack at the
age of 80 years and mother died by the same causes at the
age of 50 years.
blood tests obtained glomerulus filtration rate of 25 ml /
min / m2, the fasting blood glucose 11 mmol / liter, LDL
cholesterol 5.0 mmol / L, HDL cholesterol of 0.7 mmol / L /
of physical examination found blood pressure is 170/95
mmHg. Pulse 92 times per minute. Other physical
examination within normal limits.
 Key word
 A man 71 yo
 complaints of discomfort in the chest accompanied
by a feeling hard to breathe during the last 3
months, especially when climbing stairs
 history of smoking 30 cigarettes per day
 history of family by heart attack (father died at the
age of 80 years and mother at the age of 50 years)
 GFR 25 ml / min / m2
 fasting blood glucose 11 mmol / liter
 cholesterol 5.0 mmol / L
 HDL cholesterol of 0.7 mmol / L
 blood pressure is 170/95 mmHg
 Pulse 92 times per minute
 1. classification of cardiac and non-cardiac chest pain

 Pleuritic chest pain

Pleuritic chest pain may be caused by the:
Diffusion pelura due to lung infection, pulmonary
embolism, malignancy or inflammation
subdiafragmatik; pneumothorax and
penumomediastinum
 Non pleuritic chest pain

1. Kardial : Myocardial ischemia,Mitral valve

prolapse, Severe aortic stenosis
 2. Perikardikal
Pain perikardila location in the sternal region and
preokordinal area, but can spread to the epigastric,
neck, shoulders and back.
Diaphragmatic pericardial inflammation can cause
pain epigastrum lateral and back as pancreatitis or
kolesistesis

3. Aortal
Patients with hypertension, koartasio aorta, chest wall
trauma is a high risk for aortic displacement.

4. Gastrointestinal 6. Functional
5. Mulkuloskletal 7. pulmonary

Anwar, T.Bahri. NYERI DADA.2004,1-USU Respository. Hal 1-3

2. Normal value of blood test in the
scenario
Blood glucose
Cholesterol
Blood Pressure
 Pulse
Bradicardi : <60 per minute
Normal : 60 – 100 per minute
Takicardi : > 100 per minute
Reference:
1. http://digilib.unimus.ac.id/files/disk1/125/jtptunimus-gdl-chairulper-6215-2-babii.pdf
2. www.repository.usu.ac.id/bitstream/.../4/Chapter%20II.pdf
3. http://repository.usu.ac.id/bitstream/123456789/23512/5/Chapter%20II.pdf
 4. causes of chest pain from the above scenario

Reference:
T.R. Harrison, etc. Harrison’s Principles of Internal Medicines. 16 th Editon. Pages
1434-1435
 precipitating factors and risk factors of
chest
factore can change factor can’t change
 Smoking • Age
• Gender
 Hipertension
• Family history
 Disiplidemia • Etnes
 Diabetes Melitus
 Obesity dan metabolic
syndrome
 Stress
 Fat diet with high calory
 identity
Reference:
Majid, Abdul. Fakultas Kedokteran Universitas Sumatera Utara. Repository.usu.ac.id.
2007.
 5. relation with the family history of chest pain

 Family history of premature coronary artery disease is a risk

factor for development of incident cardiovascular disease.
family history for ischemic heart disease is a significant and
independent risk factor for coronary artery disease.
Epidemiological and family studies have repeatedly shown
that genetic predisposition accounts for 40% to 60% of the
risk for CAD
 Family history of CVD modifies future CVD risk depending
on the number and age of affected first-degree relatives.
Siblings of patients with CVD have about a 40% risk
increase, while offspring of parents with premature CVD
have a 60% to 75% risk increase. Consistent definitions of
premature CVD would allow a better estimate of the true
attributable risk.
6. relation between smoke and the
sympotms
 Smoke contains many harmful substaces, one of which is
the CO gas. CO gas has the ability to bind to Hb higher
than oxygen. So, if there is smoke inhaled, Hb bring
more CO than oxygen. O2 deficient cells will do
compenstate by way of spasm. When the spasm lasts
long, the blood vessels will be damaged and it can be
atherosclerosis. Atherosclerosis can cause hypertension,
if hypertension lasts long, it can be grafting blood vessels
in the heart (coronary arteries), and ultimately lead to
myocardial infarction. One of the symptoms of
myocardial infarction is chest pain.

Reference: Murray, K Robert, dkk. 2014. Biokimia Harper ed.27. Penerbit Buku
Kedokteran:EGC
 7. relationship of physical activity with
chest pain
if the coronary artery stenosis or narrowing of the
misbehaving spasme, coronary artery supply is
insufficient so that will happen an imbalance
between the supply and the demand, this will
provide a distraction. And at the time of the
activities of an increase in oxygen supply needs,
this will cause hypoxic tissue that will result in
increased metabolic results, such as lactic acid.
Deficiency of oxygenation of tissue infarction can
cause chest pain

Reference: Rilanto, Lily Ismudiati.dkk. Buku Ajar Kardiologi. FKUI.2003. Hal.160)

8. measures to determine the diagnosis of
disease diagnosis
 General Situation
 Checking Blood Pressure
 Examination
Palpation
Rhythm
 Hand
Peripheral cyanosis
Pale
capillary refill time
Temperature
Edema stretch
Decreased
Penggadaan (clubbing)
  Examination Jugular Veins
 Examination of the Heart
 Inspection
 palpation
 percussion
 Heart sounds
 The rhythm and frequency heart sounds

Reference: Candrawati, Susiana. Physical examination Cardiovascular System. In

http: //www.scribd.com/doc/16636735/Pemeriksaan-Fisik-kardiovaskuler [2 April
2016]
 9. Basic management to results the
diagnosis
 Nitrat : can cause vasodilatation so it can be
headache and hypotension. Nitrogliserin
(GTN 2,5 mg) or ISDN (10 mg or 20 mg) gave
peroral, 2-3 times a day, it can decrease the
frequency of angina. Sublingual nitrat, such
as GTN 2,5 mg or ISDN 5 mg diberikan if it
needed when it suddenly attack.
 Antiplatelet or Antiagregation : to keep if the
plack rupture not cause atherotrombosis that
can become acute coronary syndrome.Such as
aspirin (80-100 mg) orclopidogrel.
B-Blockers and Calcium Channel Blocker : If nitrat and
antiplatelet had been gave ans still have a pain,
hypertension, so it can be added with B-Blockers and
Calcium Channel Blockers. And if the angina still
unstable so it can be gave triple theraphy combine nitrat,
B-Blockers and Calcium Channel Blockers. 

Reference :
 Prof. Dr. dr. Peter Kabo, PhD, MD. 2010. Bagaimana Menggunakan Obat-Obat
Kardiovaskular Secara Rasional. Jakarta : Badan Penerbit FK UI. Hal 132-138.
 I Rilantono, Lily. 2012. Penyakit Kardiovaskular. Jakarta : Badan Penerbit FK UI.
Hal 136.
 10. differential diagnosis of this scenario
A. ACUTE MYOCARDAL INFARCTION

Acute Myocardial Infarction (AMI) is an interruption of

blood flow to the heart which causes the heart muscle
cells undergo hypoxia. Blood vessel The coronary
blockage so that the blood flow to the heart muscle
stops, except for a small amount of collateral flow from
the surrounding blood vessels. Muscle areas that did
not receive blood flow or current is very little that can
not maintain muscle function heart, said experience is
the development of myocardial infark.Infark
Amal Kumar Banerjee, Et all. Guidelines for Management of Acute Myocardial Infarction. Vol
59.2011
 ANGINA
Angina–also sometimes called angina pectoris, is a
symptom of an underlying heart condition. It means
that the heart is not getting enough blood and as a
result, not enough oxygen. This decrease of oxygen
being delivered to the muscle of the heart happens if
one or more coronary arteries are narrowed or blocked,
a condition called atherosclerosis.
 Stable angina
occurs when the heart has to work harder than normal, during
exercise, for example. It has a regular pattern,
 Unstable angina
is more serious, and may be a sign that a heart attack could
happen soon. There is no predictable pattern to this kind of
angina; it can just as easily occur during exercise as it can while
you are resting. It should always be treated as an emergency.

Gilles Montalescot. 2013 ESC Guidelines On The Management Of Stable Coronary Artery
Disease Addenda. Esc Guidelines Addenda. European Heart Journal.2013
 CORONARY ARTERY DISEASE

Atherosclerosis is the main cause of coronary artery

disease. The process begins as disruption of
endothelial function due to the accumulation of
lipoprotein droplets in the intima of the coronary
vessels. Water insoluble lipids are carried in the
bloodstream attached to water soluble apolipoproteins
(lipoproteins). High concentrations of low density
lipoprotein (LDL) can permeatean already disrupted
or dysfunctional endothelium where it undergoes
oxidation and, in diabetics, glycation. Modified LDL
attracts leukocytes into the intima and can be
scavenged by macrophages leading to the formation
of foam cells. These cells replicate giving rise to one of
theK.earliest.
Munther Homoud, et all. Coronary Artery Disease.Tufts-New England Medical
CenterSpring.2008.
Thank you