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now reduced to 5 sticks per day. Overall, his has smoking history around 45
packs year. He consumes alcohol occasionally especially during festive seasons.
He has no drug misuse history.
Medications
Currently, the patient is on T. aspirin 150mg OD, T. simvastatin 40mg ON,
Vasteral 20mg TDS, perindopril 2mg OD, Isordil 20mg TDS, bisoprolol 5mg OD,
metformin 1g BD, necrobion 1/1 OD and S/c mixtard.
Allergies
No known allergies to food or medications.
Review of systems
The patient claims that his vision slightly reduced even though he still carry out
his normal function. Otherwise, review of GI, endocrinology, nephrology, neurology, and
other systems reveal no abnormalities.
Physical Examination
The patient is positioned at 45 degrees and has an adequate exposure.
On general inspection, patient is alert and conscious. He looks comfortable at
rest, not tachypneic, not fatigue and not jaundiced. He is not obese and has
branula on left dorsum of hands. On hands inspection, the palm looks pale.
Otherwise, there is no clubbing, stigmata of infective endocarditis and cutaneous
or tendinous xanthomata over elbows or joints. His pulse is 74 beats per minute,
regularly regular, with low volume. There is no radial-radial delay, radial-femoral
delay or collapsing pulse. His blood pressure is 132/68 mmHg sitting on right
arm, respiratory rate at 19 per minute, and temperature was 37 degree Celsius.
On face inspection, there is no scleral icterus, but he has conjunctival pallor and
corneal arcus. There is no xanthelasma and facial flushing. He has poor oral
hygiene. No central cyanosis and no high arched palate.
Physical examination of his neck is unremarkable where JVP is not raised and his
carotid arteries are of good volume and character.
On chest inspection, no scars, chest deformities or visible pulsation that could be
found. On palpation, apex beat is palpable at 5 th intercostal space, mid clavicular
line. There is no palpable heaves and thrills.
On auscultation, first and second heart sounds are heard over four areas with no
added sound. There is no murmur that can be heard. There is no bibasal crepts
and no sacral edema.
The liver is not enlarged and there is no pitting edema.
Summary
In summary, Mr BH a 62 year-old gentleman, with a history of diabetes mellitus,
hypertension, dyslipidemia and three vessels disease, presented with severe
chest pain associated with sweating and shortness of breath preceded by
intermittent fever and productive cough.
On physical examination, patient is pale with wide pulse pressure and displaced
apex beat. Otherwise, there is no other positive finding.
Diagnosis
a) Provisional: ST elevation myocardial infarction. Patient has symptoms
which is very characteristic of myocardial infarction. The pain also
accompanied by sweating. Patient also has three main risk factors for
myocardial infarction which is diabetes, hypertension and dyslipidemia.
The fever might be the precipitating factor.
b) Differentials: 1) Unstable Angina. This is because the pain is classical for
angina pain. He also had it even at rest suggestive for unstable angina,
instead of stable. However, further investigation is needed in order to
differentiate it from myocardial infarction.
2) Infective endocarditis. The pain was preceded by history of intermittent
fever which is common in infective endocarditis. Other than that, physical
examination reveals poor oral hygiene which may be a contributor to
infective endocarditis. However, there is no evidence of murmur which
goes against infective endocardidtis. Having said this, early presentation
of infective endocarditis where the valvular damage is still minimal and
the vegetation is still low, the murmur might not be present.
Investigations
1. Full blood count: Patient is pale. This is in keeping with low hemoglobin
result in the patient which shows that patient is having hypochromic
microcytic anemia. This can be due to several reasons such as iron
deficiency, thalassemia and spherocytosis. Most likely, it is due to iron
deficiency which can be due to dietary, bleeding (hence, need to do
coagulation profile) and malabsorption. This need to be determined as it
can cause recurrent or worsen the patient condition after he is discharge
(if it is not treated).
White blood cell is high. This can be due to infection or sometimes white
blood cell is high in ischaemic heart disease. It is good to check patients
temperature and if the temperature is elevated, this can be the trigger of
patients condition. Blood culture and sensitivity also need to be done as it
can shows if there is any infective organism, especially organism common
in infective endocarditis (IE). On top of that, patient has history of
intermittent fever. Hence, IE need to be rule out as it can worsen this
patients condition (valvular disease).
Results:
Test
Results
WBC
RBC
HGB
HCT
MCV
12.510^3 uL
3.810^6 uL
10.4 g/dL
30.5%
79.6 fL
Reference
Range
4.0-10.0
4.5-5.5
13.0-17.0
40.0-50.0
83.0-101.0
MCH
MCHC
PLT
NE%
LY%
MO%
EO%
BA%
27.2 pg
34.1 %
36210^3 uL
63.9%
24.3%
8.4%
4.0%
0.2%
27.0-32.0
31.5-34.5
150.0-400.0
40.0-80.0
20.0-40.0
2.0-10.0
1.0-6.0
0-1.2
Level
High
Low.
Low.
Low.
Low. Iron
deficiency anemia
could be the
cause.
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Results
Level
276
Reference
Range
<190 U/L
Creatinine Kinase
(CK)
Aspartate
aminotransferase
(AST)
Lactate
Dehydrogenase
(LDH)
0-40 U/L
Normal
136
Normal
High
Result
Reference
Range
Level
PT
INR
12.2 sec
1.4
9.4-12.5
1.0-1.2
aPTT
32.7
25.3-32.8
Normal
Increased. The risk
of bleeding related
events increases as
the patient is not
on any
anticoagulation
drugs.
Normal
Result
Total protein
Albumin
Globulin
Total bilirubin
ALT
ALP
Calcium
Inorganic
phosphates
Calcium total
Corrected
calcium total
Magnesium
61 g/L
24 g/L
37 g/L
4 umol/L
10 U/L
70 U/L
2.34 mmol/L
1.20mmol/L
Reference
Range
64-83
35-50
20-36
3-21
<41
40-130
2.1-2.55
0.74-1.52
Level
1.97
2.28
2.15-2.50
2.15-2.50
Low
Normal
0.99
0.66-1.07
Low
Low
Low.
Mildly high.
Normal
Normal
Normal
Normal
Normal
Result
Sodium
135 mmol/L
Reference
Range
136-145
Level
Mildly low.
Potassium
Urea
Creatinine
Chloride
3.7 mmol/L
6.7 mmol/L
88 umol/L
99 mmol/L
3.5-5.1
2.76-8.07
62-106
98-107
Normal
Normal
Normal
Normal
6. HbA1c. Patient has medical history of diabetes for 10 years and currently
on S/c mixtard. Poor glycaemic control can predispose patient to various
macrovascular complications and one of them is coronary artery disease.
Result shows poor glycaemic control and this can be due to poor
compliance to medication or diet.
Test
Results
HbA1c (NGSP)
HbA1c (IFCC)
8.6
70
Reference
Range
<6.5%
<48 mmol
Level
High
High
7. ECG: To confirm if there is any acute coronary syndrome, to know the type
and also the sides of infarction, if there is any.
Results: Normal sinus rhythm. ST elevation on lead II, III and aVF. Q wave
on lead III and aVF. This means patient has inferior MI and previous infarct
as the ECG already evolved to shows Q wave.
8. Chest X ray: this is not done. But, I would like to have chest X ray to
detect any pulmonary edema and cardiomegaly.
9. Blood culture and sensitivity. To detect if there is any underlying
infection.
Result: Not available.
10.Echocardiography: To look for regional wall motion abnormalitites
(RWMA) indicate infracted area and to assess ejection fraction (EF),
valvular regurgitation or abnormalities.
Results: Left atrium slightly dilated, RWMA present, EF 45-50%, trivial AR,
trivial TR, no MR, no clot/intracardial shunt, no pericardial effusion.
Problem List
a) Main presenting problem: Inferior myocardial infarction.
b) Active problems: High HbA1c/blood glucose, anaemia, high white blood
cell, high INR.
c) Inactive problem: Smoker.
Management
1. Goal in management of STEMI is early reperfusion with primary PCI or
thrombolysis. This patient is a candidate of PCI as he presented early (<3
hours) and also for thrombolysis. He is not a known case of coagulation
disorder. However, on investigation later, it was found out that his INR is
1.4, hence thrombolysis is not a good choice. It is better to reperfuse him
with primary PCI.
2. General management as follows:
3.
4.
5.
6.
7.
8.
Referral Letter
Cardiology Department,
Penang Hospital, Residency Road,
10990 Penang
10th May 2015
Dr A,
Cardiology Specialist Department,
Penang Hospital, Residency Road,
10990 Penang
Dear Dr A,
Re Mr BH Age: 62 IC no: 530817075029
Kindly please see this patient and advice regarding management of this patient.
History
In summary, Mr BH a 62 year-old gentleman, with a history of diabetes mellitus,
hypertension, dyslipidemia and three vessels disease, present with severe chest
pain associated with sweating and shortness of breath preceded by intermittent
fever and productive cough.
Allergies
No known allergies.
Physical Examination
On physical examination, patient is pale with wide pulse pressure and displaced
apex beat. Otherwise, there is no other positive finding.
Investigations
1. Full blood count. Patient has high white cell count (12.5 u/L) and low
haemoglobin (3.8 g/L)
2. Cardiac enzymes shows high creatinine kinase (276 U/L)
3. Coagulation shows high INR (1.4)
4. Renal profile shows slightly low sodium (135 mmol/L).
5. Liver function test shows low total protein (61 g/L) and albumin (24g/L)
6. ECG shows sinus rhythm with inferior MI.
7. Echocardiography shows Left atrium slightly dilated, RWMA present and EF
45-50%.
8. HbA1c is high (8.4%)
Management
He is on Ramipril, Digoxin, Carvedilol, Spironolactone and Lasix. He is started on
Augmentin and Azithromycin as a prophylaxis to valvular heart disease.