CONFIDENTIAL

MEDICAL POSTING

YEAR 3

CASE WRITE UP

Faculty of Medicine, UiTM

Name of student: Mohd Affarizal bin Rosli

Matrix no.: 2006833002

Supervisor: Dr. Effarezan Abdul Rahman

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NAME: Mrs. Ainul Rofidah R/N: 64273

D.O.B: 30/12/1947 AGE: 62 years old

SEX: Female ETHNIC GROUP: Malay

OCCUPATIONAL: Housewife MARITIAL STATUS: Married

DATE OF ADMISSION: 01/02/2010 WARD: 5D

DATE OF DISCHARGE: 04/02/2010 INFORMANT: Patient

CHIEF COMPLAINT

Mrs. Ainul Rofidah, 62 year old, Malay housewife, admitted on 01/02/2010 with

the complain of chest pain 5 hours prior to admission.

HISTORY OF PRESENTING COMPLAINT

She was well until about 5 hours prior to admission when she experienced sudden

onset of chest pain which radiates to her jaw, right back and right upper arm. She

described the pain as tightness which was so severe until wake her up from her sleep. The

pain was preceded by palpitation and cough which she experienced a few hours before

sleep but she denied having sputum, shortness of breath, orthopnea, and PND. Because of

that, she take 2 tablet of GTN to relieved it after the first tablet still did not relieved the

pain. According to her, the pain did relieved for about 20 minutes, however started to

recur again but becomes less severe. Because of that, her husband brought her to

Selayang Hospital.

There was no history of leg swelling, headache, hemoptysis, nausea, vomiting,

fever, difficult or painful swallowing. She also denied any loss of consciousness, turns to

blue or became pale.

On further questioning, she had history of multiple hospitalization due to the same

complain which were at Selayang Hospital and Selama Hospital,Taiping since 2006.

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According to her, the pain occurring almost every month and she was hospitalized

because of that. She was worried because the pain becoming frequent lately and occurs

about 2 to 3 times in a month.

SYSTEMIC REVIEW

CNS : no loss of consciousness, no headache, no blurred vision

CVS : chest pain, palpitation, no leg swelling, no orthopnea, no paroxysmal nocturnal

dypsnea

RESP: cough, no haemoptysis, no wheezing

GIT : no vomiting, no altered bowel habit, no loss of appetite/ loss of weight

GUT : no frequency, no dysuria, no haematuria

MSK : no bone/joint pain, no joint swelling, no muscle cramp

H&L etc.: no fever, no bleeding tendency, no bruises, no swelling at the neck, axilla or

groin regions

PAST MEDICAL / SURGICAL HISTORY

She has history of multiple hospitalizations due to the same problem since 2006.

She had hypertension and hypothyroid since 2002 which she discovered when seeking

general practioner in Klinik Kesihatan. She did experienced headache and dizziness

because of that. She also had history of hospitalization in IJN for 3 days for pericardial

effusion on 2000 and complains no complication after that.

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DRUG HISTORY & ALLERGIES

Currently, she 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

Mrs. Ainul Rofidah is the eldest out of 10 siblings. All of her siblings are healthy.

Her 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. She is married with 5 children.

All of his children are well and healthy.

SOCIAL & ENVIRONMENTAL

Mrs. Ainul Rofidah lives at Taman Sri Gombak with her husband and children in

a single storey terrace house with proper water and electrical supply. She is non smoker

and not consumes any alcohol.

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PHYSICAL EXAMINATION

GENERAL EXAMINATION

On general examination, Mrs. Ainul Rofidah, moderately-built lady was alert and

conscious. She was lying comfortably on the bed. She was not in pain and not in

respiratory distress.

On examination of her hands, the hand was warm and moist. There were no

stigmata of infective endocarditis such as Janeway’s lesion and Osler’s nodes, no

clubbing, no peripheral cyanosis, and the capillary refill time was less than 2seconds.

She 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 oedema.

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 oedema.

All her vital signs were within normal range as follow;

• Blood pressure : 116/70 mmHg

• Pulse : 62bpm, normal volume, regular rhythm

• Respiratory rate: 20 breath per minute

• Temperature : 36.70C

• SpO2: 99% on air

CARDIOVASCULAR SYSTEM

On inspection of the chest, the chest move symmetrically with respiration. There

was no chest deformity, no surgical scar, no dilated superficial vein, no visible pulsation

and no skin discolouration.

On palpation, the apex beat was located at 5th intercostals space within the left

midclavicular line. No heave or thrill noted.

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On percussion revealed normal cardiac dullness.

On auscultation, normal first & second heart sound was heard. There was no

murmur.

All the peripheral pulses were palpable and the jugular venous pressure (JVP) was

not raised

RESPIRATORY SYSTEM

On inspection of the chest, the chest moves symmetrically with respiration, there

was no chest deformity, no use of respiratory accessory muscle, no surgical scar, no

dilated vein, and no intercostals, subcostals and suprasternal recession.

On palpation, the trachea was centrally located, normal chest expansion, and

normal vocal fremitus at both upper, middle and lower zone. Apex beat was palpable at

the 6th intercostals space at the left midclavicular line.

On percussion, there was normal resonance anterior and posteriorly and normal

cardiac and liver dullness were noted

On auscultation, vesicular breath sound was heard with normal air entry and

normal vocal resonance of both sides. No crepitation and rhonchi noted.

ABDOMINAL EXAMINATION

On inspection the abdomen was flat. There was no obvious swelling. The

abdomen moves normally with respiration. No visible peristalsis, no superficial dilated

vein, the umbilicus was centrally located & inverted and the hernial orifices were intact.

On palpation, the abdomen was soft, non- tender, no mass palpable. There was no

hepatosplenomegaly. The kidneys were not ballotable.

On percussion, there was no area of dullness and negative shifting dullness.

On auscultation, normal bowel sound was heard.

Per rectal revealed no abnormality.

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CENTRAL NERVOUS SYSTEM

Mental status Patient was alert, conscious and oriented to time, place and person.

Cranial nerve All cranial nerves were intact.

Muscle tone There were no muscle wasting, abnormal movement and fasciculation

of her upper and lower limb. Normal muscle tone of both upper

and lower limbs.

Muscle power Normal muscle power of both upper and lower limbs (5/5)

Reflexes All tendon reflexes were normal

Reflexes Left Right

Jaw Jerk ++ ++

Biceps ++ ++

Supinator ++ ++

Knee ++ ++

Ankle ++ ++

Plantar Down going Down going

Cerebellar Signs There was no cerebellar sign present and his gait was normal

On sensory examination, there was no impaired sensation.

CLINICAL SUMMARY

Mrs. Ainul Rofidah, 62 year old, Malay housewife who with 8 years history of

hypertension, presented on 01/02/2010 with recurrent sudden onset of chest pain, which

was partially relieved by sublingual GTN, associated with cough and palpitation 5 hours

prior to admission. Physical examination revealed unremarkable findings.

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Summary of the finding diagrammatically

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-chest pain, palpitation-chest pain, palpitation

-cough with no sputum-cough with no sputum

PROVISIONAL DIAGNOSIS

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:

1) 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.

2) 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.

3) Printzmetal’s (variant) angina

My second provisional diagnosis is 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

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presents with other vasospastic disorders such as Raynaud’s phenomenon or

migraine headaches.

INVESTIGATIONS

Several investigations were done in order to confirm the diagnosis and to assess the

severity, as well as to assess the general condition of this patient.

BIOCHEMISTRY INVESTIGATIONS

1) Full blood count

- This investigation is done to look if patient was anemic that might worsen his angina.

FULL BLOOD COUNT

Value Normal range Interpretation

RBC 3.76 (3.8-5.8) Low

WBC 7.55 (4.00-11.00) Normal

Hemoglobin 10.7 (12.3-15.3)g/dL Low

Haematocrit 33.8 (37-47) Low

Mean cell Hb 28.5 (27.0-33.0) Normal

Mean cell volume 89.9 (76.0-96.0) Normal

Platelets 191 (150-400) Normal

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AUTOMATED DIFFERENTIAL

Neutrophile % 62.9 (40.0-75.0) Normal

Lymphocyte% 27.2 (20.0-45.0) Normal

Monocytes% 5.0 (0.0-8.0) Normal

Eosinophile% 4.8 (0.0-5.0) Normal

Basophile% 0.1 (0.0-2.0) Normal

Neutrophile# 4.8 (2.9-7.9) Normal

Lymphocyte# 2.1 (1.8-4.0) Normal

Monocytes# 0.4 (0.0-1.6) Normal

Eosinophile# 0.4 (0.4-2.1) Normal

Basophile# 0.0 (0.0-0.2) Normal

Impression: normal

2) Cardiac profile

- Cardiac profile was done to further if there was infarction indicates as

increase cardiac enzymes

Cardiac enzymes Result Normal range interpretation

CK 48 55-170 Low

CKMB 1.1 <6 Normal

LDH 174 208-460 Low

AST 19 10-45 Normal

Impression: there is no elevation in cardiac enzymes suggesting less likely episode of

infarction.

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3) Electrolytes

Lab View Normal Range Result State

Urea 2.5-6.4 mmol/L 3.9 Normal

Sodium 135-150 mmol/L 141 Normal

Potassium 3.5-5.0 mmol/L 3.8 Normal

Creatinine 62-133 umol/L 60 Low

Impression: normal

SPECIFIC INVESTIGATION

Another specific investigation that helpful in diagnosing and exclusion of causes of chest

pain in this patient are:

ECG –angina –ST segment depression

-Infarction –ST segment elevation

CT scan

Chest X-ray

Cardiac catheterization with angiography (coronary arteriography)

FINAL DIAGNOSIS

→ Unstable angina

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PROGRESS DURING HOSPITALIZATION

Date Progression

01/2/2010 - patient alert and conscious but look weak

- no more chest pain and SOB seen

-On arrival, vital signs

BP: 138/78mmHg

PR: 60bpm

RR: 20breath/min

Temp: 370C,clinically afebrile

SpO2: 98% on air

o/e

- alert & conscious

- pink, no jaundice

- hydration good

02/2/2010 - patient well, comfortable

- no more chest pain and SOB seen

- tolerate orally well

- no vomiting

-vital sign monitor 4 hourly

- vital signs

BP: 110/68mmHg

PR: 68bpm

RR: 20breath/min

Temp: 370C

SpO2: 98% on air

-day 1,subcutaneous clexane 0.6mls x 3days

o/e

- alert & conscious

- pink, no jaundice

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- hydration good

03/2/2010 - patient well, comfortable

- no chest pain and SOB seen

- tolerate orally well

- no vomiting

-vital sign monitor 4 hourly

- vital signs

BP: 118/70mmHg

PR: 72bpm

RR: 20breath/min

Temp: 370C

SpO2: 98% on air

-day 2,subcutaneous clexane 0.6mls x 3days

-plan for discharge tomorrow after completing clexane

o/e

- alert & conscious

- pink, no jaundice

- hydration good

04/2/2010 - patient well, comfortable

- no chest pain and SOB seen

- tolerate orally well

- no vomiting

-day 3, subcutaneous clexane 0.6mls x 3days

-allow discharge

-discharge medications:

T. isosorbide dinitrate 10mg tds

T. aspirin 150mg OD

T. metoprolol 25mg BD

T. perindopril 2mg OD

T. lovastatin 20mg ON

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T. plavix 75mg OD

DISCUSSION

Mrs. Ainul Rofidah, a 62 years old Malay housewife 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.

She was finally diagnosed of unstable angina. Throughout the hospitalization, she

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

She was was advised to take a good lifestyle and good control of her 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

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Ventricular Failure, bradycardia, and coronary artery spasm). Nitrates are also used for

reducing symptoms,for example GTN sprayor sublingual tabsup to every ½ hours. It can

also be use as prophylaxis by giving regular oral nitrate, eg 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. Beside 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.

Name of Student : Mohd Affarizal bin Rosli

Supervisor’s Comments on Case Write-up

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Marks :

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