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 : Technician

Address : 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 Both parents had no known medical

60 Y/O 80 Y/0
illness and passed away due to old
age. No history of premature death
and malignancy in the family. No
other medical illness in other siblings.

62 Y/0, Had recent

history of heart
attack.
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, Janeway’s lesion, or Osler’s 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 : 37°C.
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 5th 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 traube’s 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 Points againts

 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.

DIFFERENTIAL DIAGNOSIS

Stable Angina

Points for Points against

 Central chest pain compressing in nature  Not preceded or aggravated by exertion
 Having risk factors : male (≥45 y/0),  Pain lasted more than 30 mintues
active smoker, diabetes mellitus,
hyperlipidemia, family history of heart
attack in family.

Pulmonary Embolism

Points for Points against

 Sudden central chest pain associated
with shortness of breath.
 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 Points against

 Sudden central chest pain associated
with shortness of breath.
 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,
Marfan’s syndrome.

Acute Pericarditis

Points for Points against

 Sudden central chest pain.  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,
Hodgkin’s lymphoma), viral
pericarditis, drug induced, etc)

Pneumothorax

Points for Points against

 Sudden chest pain associated with
shortness of breath.
 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) 9823
Lactic Dehydrogenase (LDH) 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) 15.7 g/dL
Haematochrit (HCT) 45.6%
MCV 87.9 fL
MCHC 33.7 g/dL
MCH 29.5 PG
 Platelet 293x10^9/L
Total white blood cells (TWBC) 20.74x10^9/L
Neutrophil 75.4%
Lymphocytes 15.1%
Monocytes 9.2%
Eosinophil 0.1%
Basophil 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 12.6 sec
ACTIVATED PTT (APTT)
APTT 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 6.72 mmol/L ↑

HDL-C 0.89 mmol/L
LDL-C 4.19 mmol/L ↑
Triglycerides 3.61 mmol/L ↑

6. Renal Profile

UREA 5.3 mmol/L

Sodium 132 mmol/L
Potassium 3.9 mmol/L
Chloride 101 mmol/L
Creatinine 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 angina 2. NSTEMI 3. STEMI

Ischemia without Ischemia with necrosis

necrosis
PATHOPHYSIOLOGY
Partially / transiently obstructive thrombus Complete obstruction by
intracoronary thrombus

Clinical features Chest pain (angina & associated features) and presence of risk factors
(history & physical
examination)

12- lead ECG No abnormalities, transient ST elevation, ST Persistent ST-elevation,

depression or T wave inversion new left bundle branch
block

Cardiac troponin 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 Kinase- Myocardial -Preferable in patient with clinical features & ECG diagnostic of
Band (CK-MB) STEMI.
-it normalized by 1-2 days, thus it is useful to detect reinfarction.
Cardiac Troponin T & -both have near absolute specificity & high clinical sensitivity for
Troponin I 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 & Clark’s Clinical Medicine, 8th Edition