PATIENT IDENTIFICATION

NAME: Mdm. RDOB: 30/12/1947

AGE: 68
SEX: Female
RACE/RELIGION: Malay, Muslim
ADDRESS: Kampung Jawa
OCCUPATION: Housewife
MARITAL STATUS: Widowed
DOA: 17/3/2015
DOC: 19/3/15
CHIEF COMPLAIN
Chest pain for 2 hours
 HISTORY OF PRESENT ILLNESS
Mdm. Rwas well 2 hours prior to the development of the
chest pain. The pain occurred suddenly while she was
resting in the afternoon, at the left side of the chest,
radiating to the neck & jaw, left arm and to the back. She
described the pain as tightness and being squeezed,
giving a pain score of 8 out of 10. The pain preceded
with palpitation and cough but she denied having
sputum, shortness of breath or orthopnea. Lasted for
more than 20 minutes. Changing of position
(lying/sitting/standing) doesnt give any effect to the pain.
She then took a tablet of Nitroglycerin, sublingually but it
didnt help to relieve the pain. After a while, she took
another tablet and then the pain fallout but the pain recur
again after 30 minutes but less severely.
 Her son brought her to the ED of HTAR soon after he
arrives home.
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.
She received IV Morphine at the ED to reduce her pain
further as her pain aggravated after she reached to the
hospital.
Aspirin 300 mg PO was given also together with SC
Claxane and IV Nitrates.
 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. 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 without sputum , no haemoptysis, no
wheezing
GIT : no vomiting, no altered bowel habit, no loss of
appetite/ loss of weight
GUS : no frequency, no dysuria, no haematuria, PARA
6+0, no PMB, period was regula before this.
MSK : no bone/joint pain, no joint swelling, no muscle
cramp
H&L: 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 GP 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.
 DRUG HISTORY & ALLERGIES

Currently, she is 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

Mdm. Ris the eldest out of 10 siblings. All of her siblings are
healthy. Her father had passed away due to MI 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 a widow with 5 children. Her
husband died due to lung cancer. All of his children are well and
healthy. It is a non-consanguineous marriage.
 SOCIAL HISTORY
Mdm. Ris a widowed who is currently staying with her
youngest child in Padang Jawa.
She used to be a house to house cleaner but stop about
20 years back.
She is a non smoker and a non-alcoholic person.
She still lives in an active lifestyle as she does most of
the house chores all by herself.
PHYSICAL EXAMINATION
 GENERAL EXAMINATION

On general examination, Mdm. Rafidah, moderately-built

lady was alert and conscious. She was lying comfortably
on the bed in upright position (bed pronated to 45 o). She
was not in pain and not in respiratory distress.
She was not pale, not jaundice and have no cataract.
The hydration status and dentition were good. There was
no oral candidiasis noted. There was no pitting oedema.
 Vital Signs
Blood pressure : 130/85 mmHg
Pulse : 68bpm, good volume, regular rhythm, no
collapsing pulse, no radial-radial delay. Radial-femoral
delay not examined. (Normal pulse rate)
Respiratory rate: 20 breath per minute
Temperature: 36.70C
SpO2: 99% on air
 Hands
Warm to touch, dry
No tobacco stain
No peripheral cyanosis
No clubbing
No flapping tremor
No muscle wasting
No palmar erythema
CFT <2seconds
 No eczema
No scar or bruises
No osler nodes
No splinter hemorrhages
No janeway lessions
Brachial pulse felt.
 Face
Face symmetrical, no deformities
There was no temporalis wasting
No conjunctival pallor
No jaundice
No xanthelasma
No corneal arcus
No petechial haemorrhage
No horner syndrome
 Mouth
No central cyanosis.
Dental caries seen.
Poor dental hygiene.
 Neck
No lymphadenopathy
JVP was not elevated.
Carotid pulse felt.
No thyroid enlargement
 Lower Limbs
Warm to touch
No pallor
No splinter hemorrhage or clubbing
No bilateral leg swelling
No erythema nodosum
No signs of deep vein thrombosis.
Femoral pulse not examined.
Popliteal pulse was not felt, posterior tibialis pulse and
dorsalis pedis pulse was felt.
Radial-femoral delay not done.
 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.
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.
 Posterior Chest Examination
Patient was told to sit in an upright position.
Chest expansion is bilaterally symmetrical.
On percussion, resonance herd.
Bronchial breath sound was heard with no added sound.
Vocal resonance increases equal bilaterally.
No sacral edema.
 SUMMARY
Mdm. Rafidah, a 68 years old lady was apparently well
before developing chest pain which was partially relieved
by sublingual GTN, associated with cough with sputum
production and palpitation, 2 hours prior to admission at
HTAR. She is a known case of hypertension,
hypothyroidism and similar episodes of chest pain since
2006. there is a positive family history. Physical
examination revealed unremarkable findings.
 ACUTE CORONARY SYNDROME

PROVISIONAL DIAGNOSIS
 DIFFERENTIALDIAGNOSIS
POINTS FAVOUR POINTS AGAINST
ACUTE CORONARY Happens at rest
SYNDROME Partially released by
nitrates (after 2nd tablet)
Severity: high
Radiates to neck & jaw, left
arm and to the back
STABLE ANGINA Partially relieved by nitrates Happens at rest
Radiates to arm and neck Severity high
Prolonged time
No breathlessness
PULMONARY Chest pain No hypotension
EMBOLISM Cough No dyspnea

PERICARDIAL PAIN Radiation to back Changing of position doesnt

Severity: high affect the severity of pain
Prolonged time
No dyspnea
Common at night time
INVESTIGATIONS
ECG
FBC
CARDIAC MARKERS
CXR
 ECG
No picture
HR was regular, at 80bpm
Sinus tachycardia present with diminished of P wave
with presence of QRS complex.
ST segment NORMAL (no elevation or depression)
 FBC
FULL BLOOD COUNT

Value Normal range Interpretation

RBC 4.3 (3.8-5.8) Normal

WBC 7.55 (4.00-11.00) Normal

Hemoglobin 13.5 (12.3-15.3)g/dL Normal

Haematocrit 39.8 (37-47) Normal

Mean cell Hb 28.5 (27.0-33.0) Normal

Mean cell 89.9 (76.0-96.0) Normal

volume

Platelets 191 (150-400) Normal

 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

 CARDIAC BIOMARKERS
Cardiac Result Normal range interpretation
enzymes

CK 48 55-170 Low
CKMB 1.1 <6 Normal
LDH 174 208-460 Low
AST 19 10-45 Normal
TROPONIN T 0.002 0-0.1mcg/L Normal
TROPONIN I 0.21 0-0.4 Normal

Impression:thereisnoelevationincardiacenzymes
suggestinglesslikelyepisodeofinfarction.
 CXR
No pictures.
No cardiomegaly.
Lungs are clear.
 PROPOSED INVESTIGATIONS
ECHOCARDIOGRAM
CORONARY ANGIOGRAPHY
CT SCAN
CARDIAC MAGNETIC RESONANCE
THYROID FUNCTION TEST
PERCUTANEOUS CORONARY INTERVENTION
TREATMENT RECEIVED
 Date Progression
17/3/2015 - 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
18/3/2015 - patient well, comfortable - vital signs
- no more chest pain and SOB seen BP: 110/68mmHg
- tolerate orally well PR: 68bpm
- no vomiting RR: 20breath/min
-vital sign monitor 4 hourly Temp: 370C
-day 1,subcutaneous clexane 0.6mls SpO2: 98% on air
x 3days
o/e
- alert & conscious
- pink, no jaundice
- hydration good
19/3/2015 - 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
20/3/2015 - 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
T. plavix 75mg OD
 FINAL DIAGNOSIS
UNSTABLE ANGINA because of unremarkable reading
investigations where ST was not elevated, together with
cardiac markers.
 PROGNOSIS
Mdm. Rfelt better after the hospital stay and being
treated. She complained of no chest pain during the stay.
She is discharged with prescribed medications. Advised
for a check up in 1 month or when the symptoms
repeated.
I have worked hard Dr.
Please give me good marks
DISCUSSION
 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.
 UA/NSTEMI is a product of inadequate supply and/or
increased demand of oxygen to the myocardium. There
are 5 causes of UA/NSTEMI. First, the most common
cause is decreased myocardial perfusion from coronary
artery narrowing that may be caused by a non-occlusive
thrombus. Second, a dynamic obstruction caused by a
spasm in the coronary artery may be occurring. Third,
there may be narrowing of the vessel without spasm or
thrombus formation. Fourth, inflammation in the vessel
related to infection may be the cause for UA/NSTEMI.
Finally, there may be secondary UA that is caused by
other factors such as fever, hypotension, thyrotoxicosis,
or anemia
 Along with the possible causes of UA/NSTEMI there are
3 common categories for the presentation of UA. First,
rest angina occurs while the patient is at rest and lasts
for more than 20 minutes. Second, new-onset angina
causes marked limitation of regular activity; finally,
increasing angina is angina that occurs more often and
lasts longer than normal.
 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 Ventricular
Failure, bradycardia, and coronary artery spasm).
Nitrates are also used for reducing symptoms, for
example GTN spray or sublingual tabs up to every
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.