Presenting Complaint

Mr BH, a 62-year-old Malay gentleman presented to Penang General Hospital with severe chest pain associated with sweating and shortness of breath for one day and fever

History of Presenting Complaint

The patient first experienced the chest pain at 5.00pm while he was walking to his room and later arrived at Penang General Hospital at 6.00pm. He describes the pain as heavy in nature, constant and very severe at 10 out of 10. The pain radiates to the arm but not to the jaw. The pain does not go away by resting and he did not try any medication. The pain caused him to sweat profusely and he also experienced shortness of breath during the attack.

However, there is no palpitation, nausea and vomiting, paroxysmal nocturnal dyspnea, orthopnea, headache and giddiness.

In emergency, he was reperfused with IV tenecteplase 7.5ml

The pain is preceded by four days history of intermittent fever associated with chills and rigors, especially at night. He took paracetamol to temporarily relieve the fever. The patient also coughs which productive of yellowish sputum during those four days.

There is no travel history of him went to recreational area or went for jungle trekking, no contact history with sick or TB patient, no rash, no loss of appetite and loss of weight.

Past Medical History

The patient has 10 years history of diabetes mellitus, hypertension and dyslipidemia and under follow up in Klinik Kesihatan Bayan Baru. The patient also has three coronary vessels disease and was planned for bypass somewhere in May 2015. He has past surgical history for amputation of toes due to diabetic foot ulcer in 2011.

Family History

His mother already passed away at the age of 68 due to heart disease which patient unsure if it was an attack or failure. His father passed away at the age of 77 with no known underlying medication. He is the eldest out of four siblings and two of them have hypertension and diabetes. The patient is married and blessed with five children.

Social History

The patient is married and currently living with his daughter in an apartment in Bayan Baru at 8th floor. He is ADL independent and used to works at a printer shop for 5 years and previously he worked in a factory. He smoked during his early 20s up till now. He used to smoke as much as 30 cigarettes per day and 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 5th 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 patient’s temperature and if the temperature is elevated, this can be the trigger of patient’s 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 patient’s condition (valvular disease).

Results:

Test Results Reference Range LevelWBC 12.5×10^3 uL 4.0-10.0 HighRBC 3.8×10^6 uL 4.5-5.5 Low. HGB 10.4 g/dL 13.0-17.0 Low. HCT 30.5% 40.0-50.0 Low. MCV 79.6 fL 83.0-101.0 Low. Iron deficiency

anemia could be the cause.

MCH 27.2 pg 27.0-32.0 NormalMCHC 34.1 % 31.5-34.5 Normal

PLT 362×10^3 uL 150.0-400.0 NormalNE% 63.9% 40.0-80.0 NormalLY% 24.3% 20.0-40.0 Normal

MO% 8.4% 2.0-10.0 NormalEO% 4.0% 1.0-6.0 NormalBA% 0.2% 0-1.2 Normal

2. Cardiac enzymes. There is elevation in the creatinine kinase level. While this is not accompany by elevation in the AST and LDH level, this can be due to either the CK elevation is from oher sources and not specific to the heart or because the sample is early and the AST and LDH was not raised just yet. Hence, this can be confirmed by repeating the cardiac enzymes again the second and third day and also by doing ECG.

Test Results Reference Range LevelCreatinine Kinase (CK) 276 <190 U/L High

Aspartate aminotransferase (AST)

9 0-40 U/L Normal

Lactate Dehydrogenase (LDH)

136 135 – 225 U/L Normal

3. Coagulation test. To know if there is any derangement in the coagulation profile. Infarction and thrombosis will worsen by derangement in the coagulation profile as the plaque rupture and the thrombus formation in a coronary vessel can happen easily. Besides that, this needs to be monitor or need to know the baseline before starting the patient on any anticoagulant and antiplatelet.

Test Result Reference Range LevelPT 12.2 sec 9.4-12.5 Normal

INR 1.4 1.0-1.2 Increased. The risk of bleeding related events increases as the patient is not on any anticoagulation drugs.

aPTT 32.7 25.3-32.8 Normal

4. Liver function test. This is done because albumin transports various substances and alterations in albumin level affect platelet function. Besides that, liver also involved in the synthesis of various coagulation factors. Patients who are low in protein and albumin also will heals slower and take longer time to recover.

Total calcium is low, but corrected calcium is normal. This may be due to low albumin level in this patient. The albumin and total protein is low which can be due to imbalance diet or

acute inflammatory response. Low albumin can also be due to defect in synthesis due to hepatocyte damage. However, this is unlikely in this patient as the ALT is not elevated.

Test Result Reference Range LevelTotal protein 61 g/L 64-83 Low

Albumin 24 g/L 35-50 Low. Globulin 37 g/L 20-36 Mildly high.

Total bilirubin 4 umol/L 3-21 NormalALT 10 U/L <41 NormalALP 70 U/L 40-130 Normal

Calcium 2.34 mmol/L 2.1-2.55 NormalInorganic

phosphates1.20mmol/L 0.74-1.52 Normal

Calcium total 1.97 2.15-2.50 LowCorrected calcium

total2.28 2.15-2.50 Normal

Magnesium 0.99 0.66-1.07 Low

5. Renal profile: To check renal function, whether it is affected by chest pain or if there is any electrolyte imbalance which complicate the patient current condition. The sodium level is low. This can be due to low sodium/salt intake or because the patient is on bisoprolol, hence lead to hyponatremia. However, this is only mildly low and not of any concern.Results:

Test Result Reference Range LevelSodium 135 mmol/L 136-145 Mildly low.

Potassium 3.7 mmol/L 3.5-5.1 NormalUrea 6.7 mmol/L 2.76-8.07 Normal

Creatinine 88 umol/L 62-106 NormalChloride 99 mmol/L 98-107 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 Reference Range LevelHbA1c (NGSP) 8.6 <6.5% HighHbA1c (IFCC) 70 <48 mmol 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:a. Bed rest for 2-3 days in uncomplicated casesb. ECG monitoring for at least 48 hours.c. Oxygen at 2-4 L/min for 2-3 hours and continue thereafter if SaO2 remains <90% or

if there is shortness of breath tachypnea. d. Sublingual nitroglycerin 0.5mg given repeated every 5 minutes up to three doses.e. Morphine 5mg IV slow bolus with antiemetic (metoclopramide 10mg)f. Diet for the first day after MI should be liquid or soft.g. Potassium level shoud be maintained at 4-5 mmol/L.

3. Low dose aspirin 75-150 mg/day lifelong if no contraindication.4. IV beta blockers given immediately followed by long term beta blockers to reduce mortality

and improve survival. Propranolol 0.1 mg/kg IV divided into 3 doses every 5-10 minutes followed in 1 hour by 20-40 mg oral dose every 6-8 hours. Watch out for severe heart failure or sign of complete heart block.

5. ACE inhibitor improve mortality after MI. Given as soon as clinical state allows, orally and continue indefinitely. Captopril 25 mg TDS. ARB can be given if intolerant to ACE inhibitor.

6. Statin should be given regardless of lipid level. Valsartan 80 mg OD as starting dose with maximum dose of 160 mg bd.

7. Anticoagulants such as heparin 5000 units IV bolus followed by a 1000 U/hour continuous infusion titrated to maintain PTT at 2x control.

8. Post discharge and follow up:

a. Cardiac rehabilitation and supportb. Patient education, management of risk factors and lifestyle modifications especially

in this patient since he is smoking and has high glucose (HbA1c) level. Referral to smoking cessation clinic can be given or nicotine replacement therapy. Other than that, low salt diet, low intensity exercise and achieving optimum body weight is important.

c. Advise patient on driving and return to work 2-3 weeks after. Patient with physically demanding jobs may need 4-6 weeks or depending on the condition. However in this case, patient already retired. Hence, may be advised on not doing strenuous activity.

d. The patient and family is educated regarding illness and to be compliant to medication and diet.

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.

HistoryIn 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.

AllergiesNo known allergies.

Physical ExaminationOn physical examination, patient is pale with wide pulse pressure and displaced apex beat. Otherwise, there is no other positive finding.

Investigations1. 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%)

ManagementHe is on Ramipril, Digoxin, Carvedilol, Spironolactone and Lasix. He is started on Augmentin and Azithromycin as a prophylaxis to valvular heart disease.

Thank you for seeing Mr SSH.

Sincerely,

(Dr Amirul)House OfficerH/P: 012 345 6789