Case 2-Chest Pain

Alifah & Liyana

Faculty of medicine
UiTM,Malaysia

History

Mdm. Xx, 60 y.o, chinese lady known case of HPT and DM

for 10 years.
Complaint of chest pain on the day of admission.
Site : Central
Nature : Tightness
Radiation : jaw and left arm
Duration : 20 minutes
Aggravating factor : Relieving factor : GTN ( KK)
Associated symptom : nausea, sweating, dyspnoea,

 Past Medical History

- DM , HT 10 years
Surgical History
- Nil
Drug History
- For HT & DM
Allergy
- Nil

Family History
-+ve hx of HT, DM,
heart problem
Social History
-Smoker (5sticks/day)
- Occasional drinker
Diet history
- High fat food

PHYSICAL EXAMINATION
Vital Signs:
BP:135/95 mmHg
HR:92 beats/minute (regular rhythm and volume)
RR: 22 breaths/minute
General examination- obese

Cardiovascular system
Inspection:
On inspection, there is no deformity, no dilated vein,
no surgical scar, and no visible pulsation.
Palpation:
The apex beat is not palpable. There was no
parasternal heave. Thrills were also absent.
Auscultation:
S1 and S2 were heard. There was no radiation, no
murmur, no rubs and no additional sounds. S3 and S4
were not heard. There was no carotid bruit present.
The 1st and 2nd maneuver (mitral stenosis and aortic
regurgitation) reveals no significants findings.

Provisional diagnosis

Non ST elevation myocardial infarction (NSTEMI) / unstable angina

History :
-

Central chest tightness :

Radiated to jaw & left arm
20 minutes
Relieved by GTN
Associated with : nausea, sweating, dyspnoea
Known case of DM & HT ( 10 years )
+ve family hx of heart problem
Smoker ( 20 years)
fat food diet

PE :
-obese

Differential Diagnosis
1. Acute myocardial infarction
Points to support :
Points to against :
ECG : ST segment depression
Relieved by GTN
Duration : 20 minutes
2. Aortic dissection
Points to support :
severe, sudden chest pain
History of HT & DM
Points to against :
Chest Pain : tightness, not radiate to the back
No syncope
CXR : no boarding of upper mediasternal & distortion of aortic
knuckle, no right sided pleural effusion & left ventricular
hypertrophy

 Pulmonary embolism
Pros :chest pain associated with
shortness of breath
Cons :no hemoptysis and no risk factor
of
hyper-coagulability like prolong bed
rest.

Pericarditis
Pros :the patient present with chest pain
Cons :the pain not aggravated by
changes in posture like leaning forward.

investigation
General :
FBC, BUSE : no significant finding
PT, PTT : normal
CXR : normal ( No cardiomegaly,
perihilar haziness and lung fields
were clear)

Cardiac enzymes
elevation of :
Troponin T
CKMB

Lipid Profile
LIPID

VALUE

NORMAL
RANGE

REMARK
S

Total
cholestero
l

6.6

<5.17
mmol/L

Increase

Triglycerid
e

1.5

0.45 1.5
mmol/L

Normal

HDL

1.2

1.0 1.79

Normal

LDL

4.7

< 3.4
mmol/L

Increase

ECG
ST
segment
depression
T inversion

Final diagnosis

Non ST elevation myocardial

infarction (NSTEMI)

Points to support :

Central chest tightness :

Radiated to jaw & left arm
20 minutes
Relieved by GTN
Associated with : nausea,
sweating, dyspnoea
Known case of DM & HT ( 10
years )
+ve family hx of heart
problem
Smoker ( 20 years)
fat food diet

PE : overweight

IV

Lipid profile :
increase LDL & total
cholesterol
Cardiac enzyme :
Troponin T & CKMB
ECG :
ST segment depression & T
inversion

Management of acute coronary

syndrome ( NSTEMI)

Criteria for high & low for

death or MI
High risk

Low Risk

ECG abnormalities

Dynamic ST segment changes

> 0.05 mV, particularly ST
segment depression
Transient ST segment elevation
T wave inversion > 0.2 mV
Pathological Q wave
Bundle branch block
Sustain Ventricular tachycardia

Elevated Troponin level

No recurrence of chest
pain within the
observational period
No ST segment depression
or elevation but rather
negative T wave, flat T
wave or normal ECG
Without elevation of
Troponin or other
biomarker of cardiac injury

High Risk

Low risk

Management
Post hospitalization
- Medical therapy ( compliance )
- Life-style modification
: Diet : highly oily fish, fruit, vegetable, fiber & low
fats
: Exercise : Regular daily exercise
: Avoid air travel for 2 months
: Reduce & stop smoking
- Follow up ( after 3 & 5 weeks )

references
Sarawak Handbook of medical
emergencies
Oxford Handbook of clinical medicine
Davidsons, Principle & practice of
medicine