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Presenting Complaint

Mr BH, a 62-year-old Malay gentleman presented to Penang General Hospital


with severe chest pain associated with sweating and shortness of breath for one
day and fever
History of Presenting Complaint
The patient first experienced the chest pain at 5.00pm while he was walking to
his room and later arrived at Penang General Hospital at 6.00pm. He describes
the pain as heavy in nature, constant and very severe at 10 out of 10. The pain
radiates to the arm but not to the jaw. The pain does not go away by resting and
he did not try any medication. The pain caused him to sweat profusely and he
also experienced shortness of breath during the attack.
However, there is no palpitation, nausea and vomiting, paroxysmal nocturnal
dyspnea, orthopnea, headache and giddiness.
In emergency, he was reperfused with IV tenecteplase 7.5ml
The pain is preceded by four days history of intermittent fever associated with
chills and rigors, especially at night. He took paracetamol to temporarily relieve
the fever. The patient also coughs which productive of yellowish sputum during
those four days.
There is no travel history of him went to recreational area or went for jungle
trekking, no contact history with sick or TB patient, no rash, no loss of appetite
and loss of weight.
Past Medical History
The patient has 10 years history of diabetes mellitus, hypertension and
dyslipidemia and under follow up in Klinik Kesihatan Bayan Baru. The patient also
has three coronary vessels disease and was planned for bypass somewhere in
May 2015. He has past surgical history for amputation of toes due to diabetic
foot ulcer in 2011.
Family History
His mother already passed away at the age of 68 due to heart disease which
patient unsure if it was an attack or failure. His father passed away at the age of
77 with no known underlying medication. He is the eldest out of four siblings and
two of them have hypertension and diabetes. The patient is married and blessed
with five children.
Social History
The patient is married and currently living with his daughter in an apartment in
Bayan Baru at 8th floor. He is ADL independent and used to works at a printer
shop for 5 years and previously he worked in a factory. He smoked during his
early 20s up till now. He used to smoke as much as 30 cigarettes per day and

now reduced to 5 sticks per day. Overall, his has smoking history around 45
packs year. He consumes alcohol occasionally especially during festive seasons.
He has no drug misuse history.

Medications
Currently, the patient is on T. aspirin 150mg OD, T. simvastatin 40mg ON,
Vasteral 20mg TDS, perindopril 2mg OD, Isordil 20mg TDS, bisoprolol 5mg OD,
metformin 1g BD, necrobion 1/1 OD and S/c mixtard.
Allergies
No known allergies to food or medications.
Review of systems
The patient claims that his vision slightly reduced even though he still carry out
his normal function. Otherwise, review of GI, endocrinology, nephrology, neurology, and
other systems reveal no abnormalities.
Physical Examination
The patient is positioned at 45 degrees and has an adequate exposure.
On general inspection, patient is alert and conscious. He looks comfortable at
rest, not tachypneic, not fatigue and not jaundiced. He is not obese and has
branula on left dorsum of hands. On hands inspection, the palm looks pale.
Otherwise, there is no clubbing, stigmata of infective endocarditis and cutaneous
or tendinous xanthomata over elbows or joints. His pulse is 74 beats per minute,
regularly regular, with low volume. There is no radial-radial delay, radial-femoral
delay or collapsing pulse. His blood pressure is 132/68 mmHg sitting on right
arm, respiratory rate at 19 per minute, and temperature was 37 degree Celsius.
On face inspection, there is no scleral icterus, but he has conjunctival pallor and
corneal arcus. There is no xanthelasma and facial flushing. He has poor oral
hygiene. No central cyanosis and no high arched palate.
Physical examination of his neck is unremarkable where JVP is not raised and his
carotid arteries are of good volume and character.
On chest inspection, no scars, chest deformities or visible pulsation that could be
found. On palpation, apex beat is palpable at 5 th intercostal space, mid clavicular
line. There is no palpable heaves and thrills.
On auscultation, first and second heart sounds are heard over four areas with no
added sound. There is no murmur that can be heard. There is no bibasal crepts
and no sacral edema.
The liver is not enlarged and there is no pitting edema.

Summary
In summary, Mr BH a 62 year-old gentleman, with a history of diabetes mellitus,
hypertension, dyslipidemia and three vessels disease, presented with severe
chest pain associated with sweating and shortness of breath preceded by
intermittent fever and productive cough.
On physical examination, patient is pale with wide pulse pressure and displaced
apex beat. Otherwise, there is no other positive finding.
Diagnosis
a) Provisional: ST elevation myocardial infarction. Patient has symptoms
which is very characteristic of myocardial infarction. The pain also
accompanied by sweating. Patient also has three main risk factors for
myocardial infarction which is diabetes, hypertension and dyslipidemia.
The fever might be the precipitating factor.
b) Differentials: 1) Unstable Angina. This is because the pain is classical for
angina pain. He also had it even at rest suggestive for unstable angina,
instead of stable. However, further investigation is needed in order to
differentiate it from myocardial infarction.
2) Infective endocarditis. The pain was preceded by history of intermittent
fever which is common in infective endocarditis. Other than that, physical
examination reveals poor oral hygiene which may be a contributor to
infective endocarditis. However, there is no evidence of murmur which
goes against infective endocardidtis. Having said this, early presentation
of infective endocarditis where the valvular damage is still minimal and
the vegetation is still low, the murmur might not be present.
Investigations
1. Full blood count: Patient is pale. This is in keeping with low hemoglobin
result in the patient which shows that patient is having hypochromic
microcytic anemia. This can be due to several reasons such as iron
deficiency, thalassemia and spherocytosis. Most likely, it is due to iron
deficiency which can be due to dietary, bleeding (hence, need to do
coagulation profile) and malabsorption. This need to be determined as it
can cause recurrent or worsen the patient condition after he is discharge
(if it is not treated).
White blood cell is high. This can be due to infection or sometimes white
blood cell is high in ischaemic heart disease. It is good to check patients
temperature and if the temperature is elevated, this can be the trigger of
patients condition. Blood culture and sensitivity also need to be done as it
can shows if there is any infective organism, especially organism common
in infective endocarditis (IE). On top of that, patient has history of
intermittent fever. Hence, IE need to be rule out as it can worsen this
patients condition (valvular disease).
Results:

Test

Results

WBC
RBC
HGB
HCT
MCV

12.510^3 uL
3.810^6 uL
10.4 g/dL
30.5%
79.6 fL

Reference
Range
4.0-10.0
4.5-5.5
13.0-17.0
40.0-50.0
83.0-101.0

MCH
MCHC
PLT
NE%
LY%
MO%
EO%
BA%

27.2 pg
34.1 %
36210^3 uL
63.9%
24.3%
8.4%
4.0%
0.2%

27.0-32.0
31.5-34.5
150.0-400.0
40.0-80.0
20.0-40.0
2.0-10.0
1.0-6.0
0-1.2

Level
High
Low.
Low.
Low.
Low. Iron
deficiency anemia
could be the
cause.
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

2. Cardiac enzymes. There is elevation in the creatinine kinase level. While


this is not accompany by elevation in the AST and LDH level, this can be
due to either the CK elevation is from oher sources and not specific to the
heart or because the sample is early and the AST and LDH was not raised
just yet. Hence, this can be confirmed by repeating the cardiac enzymes
again the second and third day and also by doing ECG.
Test

Results

Level

276

Reference
Range
<190 U/L

Creatinine Kinase
(CK)
Aspartate
aminotransferase
(AST)
Lactate
Dehydrogenase
(LDH)

0-40 U/L

Normal

136

135 225 U/L

Normal

High

3. Coagulation test. To know if there is any derangement in the coagulation


profile. Infarction and thrombosis will worsen by derangement in the
coagulation profile as the plaque rupture and the thrombus formation in a
coronary vessel can happen easily. Besides that, this needs to be monitor
or need to know the baseline before starting the patient on any
anticoagulant and antiplatelet.
Test

Result

Reference
Range

Level

PT
INR

12.2 sec
1.4

9.4-12.5
1.0-1.2

aPTT

32.7

25.3-32.8

Normal
Increased. The risk
of bleeding related
events increases as
the patient is not
on any
anticoagulation
drugs.
Normal

4. Liver function test. This is done because albumin transports various


substances and alterations in albumin level affect platelet function.
Besides that, liver also involved in the synthesis of various coagulation
factors. Patients who are low in protein and albumin also will heals slower
and take longer time to recover.
Total calcium is low, but corrected calcium is normal. This may be due to
low albumin level in this patient. The albumin and total protein is low
which can be due to imbalance diet or acute inflammatory response. Low
albumin can also be due to defect in synthesis due to hepatocyte damage.
However, this is unlikely in this patient as the ALT is not elevated.
Test

Result

Total protein
Albumin
Globulin
Total bilirubin
ALT
ALP
Calcium
Inorganic
phosphates
Calcium total
Corrected
calcium total
Magnesium

61 g/L
24 g/L
37 g/L
4 umol/L
10 U/L
70 U/L
2.34 mmol/L
1.20mmol/L

Reference
Range
64-83
35-50
20-36
3-21
<41
40-130
2.1-2.55
0.74-1.52

Level

1.97
2.28

2.15-2.50
2.15-2.50

Low
Normal

0.99

0.66-1.07

Low

Low
Low.
Mildly high.
Normal
Normal
Normal
Normal
Normal

5. Renal profile: To check renal function, whether it is affected by chest pain


or if there is any electrolyte imbalance which complicate the patient
current condition. The sodium level is low. This can be due to low
sodium/salt intake or because the patient is on bisoprolol, hence lead to
hyponatremia. However, this is only mildly low and not of any concern.
Results:
Test

Result

Sodium

135 mmol/L

Reference
Range
136-145

Level
Mildly low.

Potassium
Urea
Creatinine
Chloride

3.7 mmol/L
6.7 mmol/L
88 umol/L
99 mmol/L

3.5-5.1
2.76-8.07
62-106
98-107

Normal
Normal
Normal
Normal

6. HbA1c. Patient has medical history of diabetes for 10 years and currently
on S/c mixtard. Poor glycaemic control can predispose patient to various
macrovascular complications and one of them is coronary artery disease.
Result shows poor glycaemic control and this can be due to poor
compliance to medication or diet.
Test

Results

HbA1c (NGSP)
HbA1c (IFCC)

8.6
70

Reference
Range
<6.5%
<48 mmol

Level
High
High

7. ECG: To confirm if there is any acute coronary syndrome, to know the type
and also the sides of infarction, if there is any.
Results: Normal sinus rhythm. ST elevation on lead II, III and aVF. Q wave
on lead III and aVF. This means patient has inferior MI and previous infarct
as the ECG already evolved to shows Q wave.
8. Chest X ray: this is not done. But, I would like to have chest X ray to
detect any pulmonary edema and cardiomegaly.
9. Blood culture and sensitivity. To detect if there is any underlying
infection.
Result: Not available.
10.Echocardiography: To look for regional wall motion abnormalitites
(RWMA) indicate infracted area and to assess ejection fraction (EF),
valvular regurgitation or abnormalities.
Results: Left atrium slightly dilated, RWMA present, EF 45-50%, trivial AR,
trivial TR, no MR, no clot/intracardial shunt, no pericardial effusion.
Problem List
a) Main presenting problem: Inferior myocardial infarction.
b) Active problems: High HbA1c/blood glucose, anaemia, high white blood
cell, high INR.
c) Inactive problem: Smoker.
Management
1. Goal in management of STEMI is early reperfusion with primary PCI or
thrombolysis. This patient is a candidate of PCI as he presented early (<3
hours) and also for thrombolysis. He is not a known case of coagulation
disorder. However, on investigation later, it was found out that his INR is
1.4, hence thrombolysis is not a good choice. It is better to reperfuse him
with primary PCI.
2. General management as follows:

3.
4.

5.

6.
7.
8.

a. Bed rest for 2-3 days in uncomplicated cases


b. ECG monitoring for at least 48 hours.
c. Oxygen at 2-4 L/min for 2-3 hours and continue thereafter if SaO2
remains <90% or if there is shortness of breath tachypnea.
d. Sublingual nitroglycerin 0.5mg given repeated every 5 minutes up
to three doses.
e. Morphine 5mg IV slow bolus with antiemetic (metoclopramide
10mg)
f. Diet for the first day after MI should be liquid or soft.
g. Potassium level shoud be maintained at 4-5 mmol/L.
Low dose aspirin 75-150 mg/day lifelong if no contraindication.
IV beta blockers given immediately followed by long term beta blockers to
reduce mortality and improve survival. Propranolol 0.1 mg/kg IV divided
into 3 doses every 5-10 minutes followed in 1 hour by 20-40 mg oral dose
every 6-8 hours. Watch out for severe heart failure or sign of complete
heart block.
ACE inhibitor improve mortality after MI. Given as soon as clinical state
allows, orally and continue indefinitely. Captopril 25 mg TDS. ARB can be
given if intolerant to ACE inhibitor.
Statin should be given regardless of lipid level. Valsartan 80 mg OD as
starting dose with maximum dose of 160 mg bd.
Anticoagulants such as heparin 5000 units IV bolus followed by a 1000
U/hour continuous infusion titrated to maintain PTT at 2x control.
Post discharge and follow up:
a. Cardiac rehabilitation and support
b. Patient education, management of risk factors and lifestyle
modifications especially in this patient since he is smoking and has
high glucose (HbA1c) level. Referral to smoking cessation clinic can
be given or nicotine replacement therapy. Other than that, low salt
diet, low intensity exercise and achieving optimum body weight is
important.
c. Advise patient on driving and return to work 2-3 weeks after. Patient
with physically demanding jobs may need 4-6 weeks or depending
on the condition. However in this case, patient already retired.
Hence, may be advised on not doing strenuous activity.
d. The patient and family is educated regarding illness and to be
compliant to medication and diet.

Referral Letter
Cardiology Department,
Penang Hospital, Residency Road,
10990 Penang
10th May 2015
Dr A,
Cardiology Specialist Department,
Penang Hospital, Residency Road,
10990 Penang
Dear Dr A,
Re Mr BH Age: 62 IC no: 530817075029
Kindly please see this patient and advice regarding management of this patient.
History
In summary, Mr BH a 62 year-old gentleman, with a history of diabetes mellitus,
hypertension, dyslipidemia and three vessels disease, present with severe chest
pain associated with sweating and shortness of breath preceded by intermittent
fever and productive cough.
Allergies
No known allergies.

Physical Examination
On physical examination, patient is pale with wide pulse pressure and displaced
apex beat. Otherwise, there is no other positive finding.
Investigations
1. Full blood count. Patient has high white cell count (12.5 u/L) and low
haemoglobin (3.8 g/L)
2. Cardiac enzymes shows high creatinine kinase (276 U/L)
3. Coagulation shows high INR (1.4)
4. Renal profile shows slightly low sodium (135 mmol/L).
5. Liver function test shows low total protein (61 g/L) and albumin (24g/L)
6. ECG shows sinus rhythm with inferior MI.
7. Echocardiography shows Left atrium slightly dilated, RWMA present and EF
45-50%.
8. HbA1c is high (8.4%)
Management
He is on Ramipril, Digoxin, Carvedilol, Spironolactone and Lasix. He is started on
Augmentin and Azithromycin as a prophylaxis to valvular heart disease.

Thank you for seeing Mr SSH.


Sincerely,
(Dr Amirul)
House Officer
H/P: 012 345 6789