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MED35112
Clinical Case Write-Up (III)
SCM : SUKD1702080
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
Systemic review
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.
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.
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 .
Chest
Lower Limb
No pedals edema
Nor deformities or surgical scars
Inspection
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.
Vital Signs
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 :
Chest X-ray
To access for any cardiomegaly.
References :