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FACULTY OF MEDICINE

DEPARTMENT OF INTERNAL
MEDICINE
CLINICAL CASES WRITE UP

NAME : MUHAMMAD ARIFF BIN MAHDZUB


MATRIC NO : MBBS 0913036
I/C NO : 920815-01-5361
YEAR : YEAR 3 (Group B1)
SUPERVISOR : Dr Syed Naquib/ Dato Dr Sapari Satwi

IDENTIFICATION DATA
Name
: Rosli bin Abdul
Age

: 51 years old

Ethnicity

: Malay

Gender

: Male

Religion

: Islam

Marital status

: Married

Occupation
Address

: Technician
: Perumahan Balok Makmur

Date of admission : 17 May 2016


Date of clerking

: 17 May 2016

CHIEFT COMPLAINT
Mr Rosli, 51 years old, an active smoker, recently diagnosed with Diabetes
Mellitus and Hyperlipidemia, presented with complaint of chest pain on day of
admission.
HISTORY OF PRESENTING ILLNESS
He was apparently well until about 3 am at day prior to admission, he had the
first attack of sudden central chest pain while having rest during the night shift
work. He described the pain as compressing, tightness and burning in nature
with pain score of 9/10 and associated with palpitation and mild shortness of
breath. However, the pain was non radiating and not aggravated by movement
or respiration. It lasted about 30 minutes and relieved after he applied ointment
on his chest. After the pain resolved he was able to sleep well.
But then about 3 hours later around 6.00 am he had the second attack of chest
pain having similar characteristics as the previous attack but it was persists with
no relieving factor and he was brought by her daughter to seek medical attention
at Emergengy Department of HTAA.
Otherwise there is no nausea, vomiting, profuse sweating and no history of
exertional chest pain before. No severe dyspnea, syncopal attack, hemoptysis
and pleuritic chest pain. There is also no orthopnea, PND, reduced effort
tolerance, leg swelling. No history of trauma to the chest prior to onset, no
underlying lung disease, similar problem before. No recent history of surgery,
long distance travelling or lower limb fracture.

Systemic Reviews:
General: There was no fever, loss of appetite, or loss of weight.
Cardiovascular system: Other than chest pain, palpitation, and dyspnea, there
was no orthopnea, paroxysmal nocturnal dyspnea, or decreased effort tolerance.
Respiratory system: There was no cough, sputum, hemoptysis, night sweat,
wheeze, or sore throat.
Gastro-intestinal system: There was no nausea, vomiting, abdominal pain,
diarrhea, constipation, hematemesis, or malaena.
Genito-urinary system: Other than polyuria and nocturia, there was no
frequency, dysuria, hematuria, hesitancy, loin pain, or discharge.
Hematological system: No purpura, epistaxis, or gum bleeding.
Neurological system: No loss of consciousness, headache, weakness, numbness,
seizures, or poor vision.
Musculo-skeletal system: No muscle cramp, joint pain, joint swelling, or stiffness.
Skin: No rash, ulcer, or pruritus.

PAST MEDICAL HISTORY


He was newly diagnosed with Diabetes Mellitus and Hyperlipidemia 2 months
ago during routine medical check-up at his workplace. On further questioning, he
actually already had polydipsia, polyuria and nocturia (3-4 times wakeup in the
night) since about 4 months prior to that but never seek any medical attention.
Then, he was given oral hypoglycemic agent and anti hyperlipidemia but never
took the medication and only did some diet change such as reduce intake of
carbohydrate and food and drink containing sugar. His blood sugar usually
around 14mmol/L. However, no other medical illnesses such as hypertension,
asthma and etc. No previous history of hospitalization.
PAST SURGICAL HISTORY
No history of surgery done before.
DRUG AND ALLERGY HISTORY
He is not on any medication and no known allergy to drug and food. He not
taking any traditional medication.

FAMILY HISTORY

62 Y/0, Had
recent history of
heart attack.

60
Y/O

80
Y/0

Both parents had no known


medical illness and passed
away due to old age. No
history of premature death
and malignancy in the family.
No other medical illness in

SOCIAL HISTORY
He married to his wife since 27 years ago and gifted with 4 children. Currently he
stayed with her wife and his 3 children at Balok in a single storey house. His
house is equipped with electricity, pipe water supply, and flush toilet. He works
as technician worker at factory and his wife work as tailor. The household
monthly income is about rm2500. He is an active smoker with 25 pack years. He
did not consume alcohol, involve in illicit drug use, or had any sexual promiscuity.
He did not active in sports.
PHYSICAL EXAMINATION
GENERAL EXAMINATION
On general inspection, my patient a medium built Malay man was
conscious and alert. He was lying at 45 propped up position. He is on nasal
prong 3L/min. He was in respiratory distress with respiratory rate of 23
breaths/min and looks lethargy but not in pain. Hydration status was good with
capillary refill time of less than two seconds.
On examination of the hand, the palm was warm and not clammy in room
temperature. There was mild clubbing. However there was no nicotine stain,
peripheral cyanosis, stigmata of infective endocarditis (splinter hemorrhage,
Janeways lesion, or Oslers node). There was no collapsing pulse, radio-radial
delay, or radio-femoral delay. There was multiple bruises over bilateral cubital
fossa which may be due to intravenous line insertion previously.
On examination of the face, he was not pale or jaundice. Oral hygiene was
good however his tongue was coated. There was no central cyanosis. The JVP
was not raised. No palpable cervical or supraclavicular lymph nodes.
On examination of the feet, there was no pedal edema.
Vital signs:
Blood pressure

: 110/70 mmHg (Normotensive)

Pulse rate

: 86 beats/minute. Regular rhythm and good

volume.
Respiratory rate

: 23 breaths/minute (Normal)

Temperature

: 37C.

SYSTEMIC EXAMINATION:
Cardiovascular Examination:
On precordium examination, the chest moved symmetrically with
respiration. There were no scars, dilated veins, or visible apex beat. The apex
beat was palpable at the left 5 th ICS, at midclavicular line. There was no
parasternal heave or thrills palpable. On auscultation, normal S1, S2 were heard.
No murmur.

Respiratory Examination:
On chest examination, the chest moved symmetrically with respiration. The
shape of the chest was normal. There was no scar or dilated veins. Chest
expansion was symmetrical bilaterally. Vocal fremitus was normal. On percussion,
the lungs were resonance. On auscultation, there is reduced breath sound with
vesicular breath sounds was heard and present of crepitation bibasally. The vocal
resonance was normal and equal bilaterally.

Abdominal examination
On inspection, the abdomen not distended. The umbilicus was centrally located.
There was no scar and no dilated veins. On palpation, the abdomen was soft and
non tender. There was no hepatosplenomegaly. The traubes space was
resonance. There was no shifting dullness and fluid thrill.
Neurological examination.
On inspection of upper limb, there was no muscle wasting, abnormal posture,
scar and fasciculation. The tone, power and reflex of both upper limbs were
normal.

The

patient

did

not

have

intention

tremor,

past

pointing,

dysdiadokinesia.
On lower limbs examination, on inspection, there was no wasting, no abnormal
posture, no scar and no fasciculation. The tone, power and reflex of both lower

limbs were normal. The coordination was intact. Pain sensation was intact and
also proprioception.
All cranial nerve was intact.

SUMMARY
Mr Rosli, 51 years old malay man, an active smoker, newly diagnosed Diabetes
Mellitus and Hyperlipidemia 2 months ago not on medication presented with
sudden non radiating central chest pain compressing in nature occured during
rest lasted for more than 30 minutes with no relieving factor associated with
palpitation and mild shortness of breath on the day of admission. On
examination, he looks lethargy and tachypnoiec, there is clubbing, and on
auscultation of the lung there is reduced breath sound and presence of
crepitation bibasally.
PROVISIONAL DIAGNOSIS
Acute Coronary Syndrome
Points for
Sudden
central
chest
pain
compressing in nature occurred
during rest with no aggravating
or relieving factor lasted more
than 30 minutes.
Having risk factors : male (45
y/0), active smoker, diabetes
mellitus, hyperlipidemia, family
history of heart attack in family.

Points againts

DIFFERENTIAL DIAGNOSIS
Stable Angina
Points for
Central chest pain compressing
in nature
Having risk factors : male (45
y/0), active smoker, diabetes
mellitus, hyperlipidemia, family
history of heart attack in family.

Points against
Not preceded or aggravated by
exertion
Pain lasted more than 30
mintues

Pulmonary Embolism
Points for
Sudden
central
chest
pain
associated with shortness of
breath.

Points against
Not pleuritic chest pain
Not associated with hemoptysis,
syncopal attack
No
risk
factor
that
can
predispose
to
pulmonary
embolism such as:
- History of long distance
travelling, recent surgery,
fracture
of
lower
limb,
myocardial infarction, heart
failure or previous VTE.

Aortic Dissection
Points for
Sudden
central
chest
pain
associated with shortness of
breath.

Points against
The pain is not described as
severe tearing in nature as
usually
occurred
in
aortic
dissection.
The pain is non radiating to the
back and it is not migrating.
No predisposing factors such as:
- Autoimmune
rheumatic
disorder, Marfans syndrome.

Acute Pericarditis
Points for
Sudden central chest pain.

Points against
The pain is not exacerbated by
movement, respiration and lying
down.
It is not relieved by sitting
forward.
No risk factors such as:
- History of MI, CKD, TB,
immunocompromised
(predisposed
to
fungal
pericarditis),
malignancy
(bronchial, breast carcinoma,
Hodgkins lymphoma), viral
pericarditis, drug induced,
etc)

Pneumothorax
Points for
Sudden chest pain associated
with shortness of breath.

Points against
It is non pleuritic chest pain.
There is only mild shortness of
breath.
No risk factors such as :
- Thin tall built (spontaneous
pneumothorax)
- No underlying lung disease
(COPD,
TB,
asthma,
pneumonia, cystic fibrosis)
- No history of trauma to the
chest prior to the pain onset.

INVESTIGATIONS
BEDSIDE
1. ELECTROCARDIOGRAM

RESULT : Acute anterior myocardial infarction. Evidence by ST elevation at V1 to


V4.
BLOOD INVESTIGATION
1. Serum Cardiac Enzymes : were markedly raised.
Cardiac enzyme

17/5/2016 (day of admission)

Creatine Kinase (CK)


Lactic Dehydrogenase (LDH)

9823
1813

Aspartate Aminotransferase (AST)

650

2. Fasting Blood glucose


Reason: to identify the risk factor (DM) in this patient.
Result : 13.6 mmol/L : raised which is correlate with the history in which he had
the hyperglycemic symptoms such as polydipsia, polyuria and nocturia and
already diagnosed with DM since 2 months ago.
3. Full Blood Count

Red blood cells (RBC)


5.32x10^12/L
Hemoglobin (Hb)
g/dL
Haematochrit (HCT)
45.6%

15.7

MCV
fL
MCHC
g/dL
MCH
PG
Platelet
293x10^9/L
Total white blood cells (TWBC)
20.74x10^9/L
Neutrophil
75.4%
Lymphocytes
15.1%
Monocytes
Eosinophil
Basophil

87.9
33.7
29.5

9.2%
0.1%
0.2%

Impression: There is leucocytosis with predominantly increased in neutrophil.


There might be presence of concurrent infection or as evidence of inflammatory
response towards acute myocardial damage secondary to myocardial infarction.
4. Coagulation Profile

PROTHROMBIN TIME
PT
ACTIVATED PTT (APTT)
APTT

12.6 sec
33.1 sec

Reason: to look for the baseline level whether it is safe to start


thrombolytic therapy in case if the patient is indicted for thrombolysis.
Impression: normal coagulation profile.
5. Lipid Profile
Cholesterol
HDL-C
LDL-C
Triglycerides

6.72 mmol/L
0.89 mmol/L
4.19 mmol/L
3.61 mmol/L

6. Renal Profile
UREA
Sodium
Potassium
Chloride
Creatinine

5.3 mmol/L
132 mmol/L
3.9 mmol/L
101 mmol/L
88 umol/L

Reason: to detect any electrolyte imbalance that will precipitate this


patient condition such as inducing cardiac arrhythmias and also help in
management of this patient.
Impression: hyponatremia

IMAGING
1. Chest x ray
Reason: to look for signs of heart failure (e.g; cardiomegaly, bats wing,
kerley B line, loss of costophrenic angle, dilated prominent upper lobe),
aortic dissection (e.g; widened aortic knuckle), pneumothorax (e.g; visible
pleural line, loss of vascular marking at lateral side,
trachea

deviation

to

the

opposite

side)

and

pneumonia (e,g; consolidation)

Result: the chest xray was taken in postero-anterior view, the exposure and
penetration were adequate. There was no cardiomegaly. No pleural line and
devoid of cardiac marking and tachea is centrally located. furthermore, there was
no Batwing appearance, Kerley B-line and pleural effusion.
2. Echocardiogram
Reason: to look for any regional wall motion abnormality which is one of the
complication of myocardial infarction. In addition, MI can also cause wall
aneurysm and mitral regurgitation.
INVASIVE
1. Coronary angiography
Reason: performed when interventional treatment is indicated.

GENERAL MANAGEMENT
Admit the patient
Secure airways- oxygen supply if patient needed
Sublingual GTN- faster administration for getting vessel vasodilation
T. Aspirin 300mg stat, followed by 150mg daily
Clopidrogrel in cases of allergy to aspirin
Reperfusion-thrombolysis (streptokinase)
Beta blocker- reduce the rate of reinfarction and recurrent ischemia
ACE inhibitors- reduce overall rate of cardivascular mortality

DISCUSSION
Mr Rosli, 51 years old malay man, an active smoker, newly diagnosed Diabetes
Mellitus and Hyperlipidemia 2 months ago not on medication presented with
sudden non radiating central chest pain compressing in nature occured during
rest lasted for more than 30 minutes with no relieving factor associated with
palpitation and mild shortness of breath on the day of admission. On
examination, he looks lethargy and tachypnoiec, there is clubbing, and on
auscultation of the lung there is reduced breath sound and presence of
crepitation bibasally.
Acute coronary syndrome is a condition which share a common underlying
pathology in which there will be plaque rupture leading to platelet aggregation
and adhesion, localized thrombosis, vasoconstriction and distal thrombus
embolization result in myocardial ischemia due to reduction in coronary blood
flow. This syndrome includes:
1. Unstable

2. NSTEMI

3. STEMI

angina
Ischemia without
PATHOPHYSIO
LOGY

Ischemia with necrosis

necrosis
Partially

transiently

obstructive

thrombus

Complete obstruction
by

intracoronary

thrombus
Clinical

Chest pain (angina & associated features) and presence of

features

risk factors

(history

&

physical
examination)
12- lead ECG

Cardiac
troponin

No

abnormalities,

transient

ST

Persistent

ST-

elevation, ST depression or T wave

elevation, new left

inversion

bundle branch block

Negative

Positive

Positive

The clinical features of ACS are as followed:


1. Symptoms: patient may presented with prolonged cardiac pain (chest,
epigastrium, back), associated with nausea, vomiting, profuse sweating,
palpitation, anxiety, restlessness and they can even collapse. However, atypical
presentation can occur in elderly, women and in diabetics.
2. Signs: from the physical examination there may be pallor, sweating, irregular
pulse, hypotension, and fourth heart sound. There may be signs of heart failure
(raised JVP, 3rd heart sound, basal crepitations) or a pansystolic murmur
(papillary muscle dysfunction/rupture, ventricular septal defect).
It is also crucial to determine the risk factors that predisposed patient to acute
coronary syndrome to help in the diagnosis and also for an effective
management of patient with ACS. The risk factors can be divided into 2 which
are:
1. Non modifiable factors: Age and gender (male> 45 y/o, female > 55 y/o),
family history of IHD.
2. Modifiable factors: Smoking, hypertension, diabetes mellitus, hyperlipidemia,
obesity and sedentary lifestyle.
The other cardiac biomarkers that are available and of higher diagnostic value
but not done in this patient are:
Creatine
Myocardial

KinaseBand

(CK-

-Preferable in patient with clinical features & ECG


diagnostic of STEMI.

MB)

-it normalized by 1-2 days, thus it is useful to detect

Cardiac Troponin T &

reinfarction.
-both have near absolute specificity & high clinical

Troponin I

sensitivity for myocardial necrosis.


-therefore it is preferable if clinical features and ECG
are suspicious but not diagnostic of MI.
-In NSTEMI: there will be absence of ST elevation on
resting ECG but elevated cardiac troponin.
-however, it will remain elevated for 10-14 days,
therefore not useful for detection of reinfarction.

However, it must be remembered that too early measurement sometimes can


misleading to low level of serum cardiac biomarkers since each of it has its own
duration when it begin to rise and became peak, therefore serial cardiac
biomarkers may be needed in patient suspected to have ACS.
Generally, the length of hospitalization for uncomplicated cases is 4-6 days.
Patients should initially be kept at bed rest. Within 24 hours after admission,
patients with uncomplicated course should begin sitting on a chair, use a bedside
commode, and should be encouraged to help themselves to shave, and eat.
Patients should be encouraged to begin walking in the room on the third day
after admission and should be fully ambulatory by 4-6 days.
In this case, patient might be able to resume his work 4-6 weeks after discharge,
as his work is not that strenuous. Driving can be resumed after about 6-8 weeks.
Regular aerobic exercise is recommended for those who had uncomplicated
course of MI.
References:
CPG Management of Acute ST Segment Elevation Myocardial Infarction
(STEMI) 2014- 3rd Edition.
Sarawak Handbook of Medical Emergencies 3rd Edition
Oxford Handbook of Clinical Medicine, 9th Edition
Kumar & Clarks Clinical Medicine, 8th Edition