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. AR R/N: --------------
D.O.B:----------- AGE: 62 years old
SEX:----------- 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.AR, 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

-cough with no sputum

-chest pain, palpitation

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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

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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 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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