case write up medicine

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:----------OCCUPATIONAL: Housewife DATE OF ADMISSION: 01/02/2010 DATE OF DISCHARGE: 04/02/2010

ETHNIC GROUP: Malay MARITIAL STATUS: Married WARD: 5D 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. According to her, the pain occurring almost every month and she was hospitalized

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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

•

SpO2: 99% on air

: 36.70C

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. On percussion revealed normal cardiac dullness. 5|Page

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 Jaw Jerk Biceps Supinator Knee Ankle Plantar

Left ++ ++ ++ ++ ++ Down going

Right ++ ++ ++ ++ ++ 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.

Summary of the finding diagrammatically 7|Page

-cough with no sputum

-chest pain, palpitation

PROVISIONAL DIAGNOSIS

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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 presents with other vasospastic disorders such as Raynaud’s phenomenon or migraine headaches.

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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 RBC WBC Hemoglobin Haematocrit Mean cell Hb Mean cell volume Platelets

Neutrophile % Lymphocyte% Monocytes% Eosinophile% Basophile% Neutrophile# Lymphocyte# 10 | P a g e

3.76 7.55 10.7 33.8 28.5 89.9 191

(3.8-5.8) (4.00-11.00) (12.3-15.3)g/dL (37-47) (27.0-33.0) (76.0-96.0) (150-400)

AUTOMATED DIFFERENTIAL 62.9 (40.0-75.0) 27.2 (20.0-45.0) 5.0 (0.0-8.0) 4.8 (0.0-5.0) 0.1 (0.0-2.0) 4.8 (2.9-7.9) 2.1 (1.8-4.0)

Interpretation Low Normal Low Low Normal Normal Normal

Normal Normal Normal Normal Normal Normal Normal

Monocytes# Eosinophile# Basophile# Impression: normal

0.4 0.4 0.0

(0.0-1.6) (0.4-2.1) (0.0-0.2)

Normal Normal 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