NAME: NOOR KHAIRIAH KAMALUDIN STUDENT ID: 2011075 CHIEF COMPLAINT Mr RS, a 40-year-old Malay man was admitted

to the hospital on 8/05/2011 with the chief complaint of progressive crushing chest pain for the past 2 months. HISTORY OF PRESENTING COMPLAINTS His chest pain started since in January 2011 and progressively getting worst in March 2011 which he fell down from his bed at night due to chest pain. He was immediately brought to Taiping Hospital by his friend which then being referred to SJH for coronary angioplasty in which has been done successfully. For the last 1 month, he experienced multiple attack of left-sided sudden crushing chest pain which is radiates to his left hand and neck. The severity of the pain is 7/10. It usually occurred during exertion and lasted for about 20 minutes in each episode. He finds it difficult to complete his house works and he can only walk for about 20 minutes without resting because of chest pain. The pain was relived within 25 minutes by GTN. The chest pain always accompanied with breathlessness. He is also complaint of pain and breathlessness at rest. He was in NYHA Class IV. Apart from breathlessness which always comes together with chest pain, he also had headache and nausea. He also experienced several episodes of sudden palpitation. He denied orthopnoea, PND, ankle swelling and syncope. He is also has no history of fever, cough, burning sensation at the chest, tenderness around the chest and previous trauma. He also has no loss of appetite and no loss of weight. MEDICAL/SURGICAL HISTORY He was diagnosed with diabetes mellitus and hypertension for the past 4 years. She was also diagnosed with myocardial infarction 5 years ago (2006). He had undergone coronary angioplasty on 2006 at IJN and on March 2011 at SJH. He also has high cholesterol level. He is an ex-smoker with background history of 20 cigarettes per day. He started smoking at the age of 19 and stopped at the age of 25. He had been admitted to hospital in 1991 due to sore throat and fever which has no further complication. DRUG HISTORY The patient does not have any drugs allergies. He took metformin and sulphonylureas (glicazide) for his diabetes previously and now his anti-diabetic medications has been stop starting this year. He takes metoprolol for his hypertension and lipitol for his hypercholesterolaemia. He takes trimetazidine for his MI. FAMILY HISTORY His father had passed away at the age of 65 due to diabetes complications. His mother is still alive and in a good condition. He has 5 siblings and all is well. He has no remarkable family history of cardiovascular disease. (FH of IHD MI in first degree relative <55yrs)

SOCIAL HISTORY He is married with 4 children. His wife and children are all in good condition. He works as an army and he was having difficulties in doing his work due to chest pain and breathlessness. He complained that he only managed to climbed stairs at maximum of level 2 at his workplace because of chest pain. He lived in 2-storey house with his wife and children. REVIEW OF SYSTEM Other systemic review is unremarkable. PHYSICAL EXAMINATION On examination, the patient was lying down comfortably at 45 degree. He is alert, conscious and is neither pale nor cyanosed. He has a brannula on his right hand but not connected to IV drip. Her respiratory rate is 12 breaths/ min. His blood pressure is 140/90mmHg, pulse rate 60 /min, regularly regular and normal volume. He is afebrile. CVS- The apex beat is mildly palpable. No heaves or thrills are present. On auscultation, the S1 and S2 can be heard with no added sounds and murmurs. Respiratory- Chest expansion was normal and symmetrical. On auscultation, vesicular breath sounds of normal intensity with no added sounds were heard. GI- Abdomen is soft and non tender. There are multiple ECG marks on the chest. Neuro- No significant finding. SUMMARY Mr RS, a 40-year-old Malay man presented with intermittent attacks of sudden progressive left sided crushing chest pain for the past 1 month and currently in NYHA class IV. It is associated with breathlessness, headache, nausea and palpitation. He was diagnosed with MI for the past 5 years; DM and hypertension for the past 4 years. On examinations, he is slightly bradycardic and has slightly high blood pressure.

DIAGNOSIS The provisional diagnosis is unstable angina. He has strong symptoms of left crushing chest pain at rest which radiates to left hand and neck. He is also presented with breathlessness, headache, nausea and palpitation. He has risk factors of acute coronary syndrome ie male, DM and hypertension. He also had previous MI. On examination, he had slight bradycardia and hypertension. He is on beta blocker for hypertension which gives positive effect of slight bradycardic.
DIFFERENTIAL DIAGNOSIS

1. Pericarditis he has symptoms of chest pain which radiates to neck and

shoulder, breathlessness and headache. However, a person with pericarditis will have typical characteristic of chest pain which are plueritis type: sharp stabbing pain, often increase with deep inspiration, coughing and swallowing and usually relieved by sitting up and leaning forward. He did not present with all the typical pericarditis chest pain and no sign of pleural/pericardial effusion which is unlikely for the person to have pericarditis. 2. costochondroitis he has symptoms of chest pain and breathlessness. However, the chest pain is not localized and non tender (tenderness will be feel by pressing on the rib joint). The pain in costochondroitis usually radiates to back and abdomen. He also has no fever. Absent of tenderness unlikely for this patient to have costochondritis.