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, 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 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 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 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, Marfan’s 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, Hodgkin’s 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 & Clark’s Clinical Medicine, 8th Edition
