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Internal Medicine I

MED35112
Clinical Case Write-Up (III)

Name : Nik Muhd Faris

SCM : SUKD1702080

Prepared for : Prof.Dr. Ma Han Ni

PATIENT’S IDENTIFICATION
RN : 6888
NAME : Mr. Aping
AGE : 62
GENDER : Male
RACE : Iban
MARTIAL STATUS : Married
OCCUPATION : Pensioned Accountant
DATE OF ADMISSION : 8/318
DATE OF CLERKING : 19/3/18
ADDRESS :Sibu
INFORMANT : Patient himself
Chief complain
Patient, a 62-year-old Iban gentleman with a known background of Hypertension, presented with
the complain of chest pain 5 hours prior to admission

History of Presenting Illness


Patient, apparently normal until 5 hours prior to admission when he experienced sudden
onset of chest pain which radiates to his jaw, right back and upper arm. He described the pain as
tightness which was so severe that wake him up from sleep. The pain was preceded by palpation
and cough which he experienced a few hours before sleep but he denied having sputum,
shortness of breath, orthopnea, and PND. Because of that, he takes 2 tablets of GTN to relieve
the symptoms after the first tablet was unable to relieve the pain. According to him, the pain did
"go away" for about 20 minutes, however started to recur again but it becomes less severe.
Because of that, his wife brought him to Sibu General Hospital.
There was no history of leg swelling, headache, hemoptysis, nausea, vomiting, fever,
difficult or painful swallowing. He also denied any loss of consciousness, turns to blue or
became pale.
On further questioning, she had multiple history of hospitalisation due to the same
complain which were at Sibu Hospital since 2006. According to him, the pain occurs almost
every month and he was hospitalised, patient worries because the pain becoming more frequently
lately and occurs about 2 to 3 times in a month.

Systemic review

Cardiovascular : Chest pain , palpitations ,no leg swelling, no orthopnea, no PND


Respiratory :Cough, no heamoptysis, no wheezing
Gastrointestinal : no vomiting, no altered bowel habit, no loss of appetite/ loss of weight
Central nervous : no loss of consciousness, no headache, no blurred vision.
Genito urinary : no frequency, no dysuria, no haematuria
Dermatology : Skin is notyellow , No rashes
Musculoskeletal : no bone/joint pain, no joint swelling, no muscle cramp
Past medical history

He has history of multiple hospitalizations due to the same problem since 2006. He had
hypertension and hypothyroid since 2002 which he discovered when seeking general practioner
in Klinik Kesihatan. He did experience headache and dizziness because of that. He also had
history of hospitalization in IJN for 3 days for pericardial effusion on 2000 and complains no
complication after that.

Drug & Allergies history

Currently, he was on: aspirin 150mg OD plavix 75mg OD x 1/12 lovastatin 20mg ON
perindopril 2mg OD thyroxine 200mg OD Sublingual GTN 2 puff PRN There is no known
allergy to foods and medications

Family history

He is the eldest out of 10 siblings. All of her siblings are healthy. His father had passed away due
to stroke at the age of 60 years old and her mother had passed away due to GIT cancer at the age
of 59 years old. He is married with 5 children. All of his children are well and healthy.

Social history

Mr. Aping lives at Taman Permai with his wife and children in a double storey terrace house with
proper water and electrical supply. He is nonsmoker and does not consumes any alcohol.

Summary
In summary, my patient is a 62-year-old Iban gentleman with underlying Hypertension admitted
to Sibu Hospital with complaint of chest pain 5 hours prior to admission.

Physical Examination
General Inspection .

On general examination, Mr. Aping, moderately-built man was alert and conscious. He was lying
comfortably on the bed. He was not in pain and not in respiratory distress. On examination of his
hands, the hand was warm and moist. There were no stigmata of infective endocarditis such as
Jane way's lesion and Osler’s nodes, no clubbing, no peripheral cyanosis, and the capillary refill
time was less than 2 seconds. He was not pale, not jaundice and have no cataract. The
hydrational status and dentition were good. There was no oral candidiasis noted. There was no
pitting edema. On examination of the neck region, there was no palpable lymph node and no
enlarged thyroid. Examination of the back revealed no bony tenderness and no sacral edema.

Vital signs [taken 19/03/18]


All his vital signs were within normal range as follow;

Blood Pressure : 116/70


Temperature : 36.7
Respiratory rate : 20
Pulse Rate : 62
Pulse volume : normal
Pulse rhythm : regular
Weight : 63 Kg
Height : 165cm (informed by patient)
BMI : 23.14

General Examination

Hand :
The palm was warm, moist
Capillary refill was normal (under 2 seconds)
No signs of clubbing , koilonychia nor leukonychia
No signs of Infective Endocarditis
No signs of scars around the arm nor tenderness around the wrist
No signs of peripheral cyanosis .

Head and face


No yellowish discoloration of sclera
The conjunctiva was not pale
The tongue looked moist with no central cyanosis
Oral hygiene was satisfactory
No angular stomatitis
No tonsillitis
JVP was not raised
No lymphadenopathy

Chest

Skin was slightly moist.


Chest expansion was symmetrical.
No surgical scars nor deformity
No rashes nor spider naevi seen
No Axillary Lymph nodes enlargement

Lower Limb
No pedals edema
Nor deformities or surgical scars

Specific Examination ( Abdomen )

Inspection

The abdomen moves with every respiration


No abdominal distention
The navel was centrally located and was not inverted
No visible gross deformity of abdomen
No surgical scars
No dilatated vein or visible pulsations
No spider naevi , caput medusa nor gynaecomastea
No yellowish appearance of skin

Palpation

On Superficial palpation
No palpable mass
No tenderness

Deep palpation
No palpable mass found
Non tender abdomen
Liver palpation
Liver was not enlarged
Spleen palpation
No enlargement of spleen

Percussion
Troube’s Space was resonant on percussion
No shifting dullness
Non ballotable kidneys

Auscultation
Bowel sound can be heard in all quadrants
No renal bruits heard

Provisional Diagnosis
Acute Coronary Syndrome, (ACS)
Based from the history and physical examination, my provisional diagnosis is acute coronary
syndrome which could be unstable angina or myocardial infarction. This is because, from the
history itself the chest pain was very typical of cardiac in origin (angina pectoris) which was
crushing in nature, occur at rest and radiates to the left upper arm. The pain was only partially
relieved by GTN which again support the history of acute coronary syndrome.
Differential diagnosis
Although the history and physical examination was very suggestive of acute coronary syndrome
as mentioned above, I would like to consider other differential diagnosis as follow:

 Pulmonary embolism
I would like to consider pulmonary embolism as the patient complain of chest pain
which is associated with cough. However, the patient of pulmonary embolism usually
presents as dyspnea and hypotension in association with chest pain which was not present
in this patient.
 Esophageal spasm
It is likely to get this condition as in old age patient and the pain did partially
relieved by sublingual GTN. However, there is no dysphagia, and no burning sensation
felt.

 Printzmetal’s (variant) angina


Printzmetal’s angina as the chest pain occur in the early morning and awaken the patient
from sleep. However, it unlikely the diagnosis as this type of angina commonly very rare,
and it is usually presents with other vasospastic disorders such as Raynaud’s phenomenon
or migraine headaches.

Laboratory Findings (followed up from 19/03 – 22/03/18)

Vital Signs

Vital Signs / 19/03/18 20/03/18 21/03/18 22/03/18


Date
BP(mmHG) 116/71 123/90 139/85 124/81
RR 22 22 23 21
PR 90 90 89 93
SpO2 (%) 99 98 96 97
Temp (C) 36.7 37 37.1 36.6

Arterial Blood Gas :

pH : 7.386 [7.35-7.45 ]
pO2 : 82.2mmHg [ 80-100 ]
pCO2 : 38.6 mmHg [ 35-45 ]
SO2© : 97.1 %
Haematological Findings
Full Blood Count
Date : 21/03/18
Treatment
Vital sign monitoring

Discussion

Mr. Aping, a 62 years old Iban gentleman who is a known case of hypertension with family
history of stroke, presented with chest pain on rest for about 5 hours associated with cough and
palpitation. Physical examination was unremarkable. He was finally diagnosed of unstable
angina. Throughout the hospitalization, he was stable and following medications were given:
• T. isosorbide dinitrate 10mg tds
• T. aspirin 150mg OD
• T. metoprolol 25mg BD
• T. perindopril 2mg OD
• T. lovastatin 20mg ON
• T. plavix 75mg OD
• subcutaneous clexane 0.6mls x 3days
He was was advised to take a good lifestyle and good control of his hypertension
Acute Coronary Syndrome (ACS) includes unstable angina and evolving MI, which
share a common underlying pathology-plaque rupture, thrombosis, and inflammation. However,
ACS may rarely due to emboli or coronary spasm in normal coronary artery, or vasculitis. It is
usually divided into ACS with ST-segment elevation or new onset of LBBB-what most of us
mean by acute MI; and ACS without ST-segment elevation-the ECG may show ST-depression, T-
wave inversion, non-specific changes, or be normal (includes non-Q wave or subendocardial
MI). The degree of irreversible myocyte death varies, and significant necrosis can occur without
ST-elevation. Cardiac troponin (T and I) are the most sensitive and specific markers of
myocardial necrosis and are the test of choice in patient with ACS.

Aspirin is one drug of choices in treating patient with angina. 75-150 mg/24 hours of
aspirin are useful to reduces mortality by 34%. B-blockers such as atenolol 50- 100mg/24 hours,
reduce symptom unless contraindications (asthma, COPD, Left Ventricular Failure, bradycardia,
and coronary artery spasm). Nitrates are also used for reducing symptoms, for example GTN
spray or sublingual tabs up to every ½ hours. It can also be use as prophylaxis by giving regular
oral nitrate, e.g. isosorbide mononitrate 10- 30mg PO or slow release nitrate. An as an alternative
way, uses of adhesive nitrate ski patches or buccal pills. Calcium antagonist also is one of drug
uses to treat angina. Amlodipine 10mg/24 hours; diltiazem-MR 90-180mg/12 hours PO. Besides
that, statin is useful in treating angina patient that present with cholesterol more than 4mmol/L.
K channel activator also are very helpful. Beside treatment using drug and therapies, good
lifestyle is also important to help improve the patient with angina. If the episodes of chest pain
occur again, admission and urgent treatment is very important.

Investigation Analysis :
FBC :
To check if patient was anemic that might worsen his angina.
Cardiac Profile :
To access the if there was infarction indicates as cardiac enzymes increased.

Electrolytes :
To abolish any possibilities of electrolytes imbalance.

ECG :
To check for :

 Angina – ST segment depression


 Infarction – ST segment elevation

Chest X-ray
To access for any cardiomegaly.

References :

• Kumar & Clark's, Clinical Medicine


• Differential Diagnosis By Howard Fussell
• Mechanisms Of Clinical Signs

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