This action might not be possible to undo. Are you sure you want to continue?
A 69 year old woman, known case of
previous MI, presenting with acute
Management, progress and
20 Summary and Conclusion
Patient described the pain as a sensation of having her “heart squeezed”. In addition to these symptoms. Patient has been complaining mild chest pain for the past one week. Since the past 5 or 6 years patient has been unable to sleep pillow-less. The pain is localized at mid-sternum with no radiation. it was rather mild and did not hinder her from carrying out her daily routine. She was immediately rushed to Hospital Sungai Buloh. She was brought to the emergency department at 7am with complaint of acute dyspnea. She remembers being brought to the hospital and triaged. Patient developed cough at synchrony with the shortness of breath. patient found she was admitted in ward. After that patient had a blackout and then remembers waking up while a central line was being inserted at her neck. The cough was described as continuous and was non-productive. When she regained conscious. 3 . After being triaged and getting ECG done. Although the pain has been present for the past week.Vikkineshwaran SM Patient History Source: The patient gives her own history and appears to be a reliable source. patient went into a state of confusion and gradually blacked out. ECG was taken and she was admitted with ward for further evaluation and treatment. Patient also has complaints of long standing orthopnoea. Chief Complaint: Madam A is 69 year old Indian woman with a past history of acute myocardial infarct 5 years back. while being admitted patient developed loss of consciousness. The pain was constantly present. She has no knowledge of what happened during this interval. Patient always sleeps with 2 pillows. History of Present Illness: Madam A had paroxysmal nocturnal dyspnoea (PNH) on Sunday morning at about 7am. She could not breathe and was coughing interminably.
1. 4. On September 2008 patient was admitted with myocardial infarction. She has developed retinopathy as a 4 . No blocks were found in angiography.Hypertension= Carvedilol 25mg twice daily . She has incomplete history of vaccination. In January 2012. 3. In July 2009. She is not allergic to any medication. Patient has been hospitalized four times previously. Patient was found to have left ventricular hypertrophy.post MI= Atorvastatin 50mg once daily.Vikkineshwaran SM Current treatment regime: -Diabetes = Metformin 500mg twice daily . patient was admitted due to acute gastroenteritis with profuse diarrhoea. patient was discharged with aspirin and Atorvastatin prescription. She has received 2 units of blood transfusion in 2012 for GI haemorrhage. diagnosed with vit. Patient describes herself to be at a serious condition at that time. Patient has been suffering from diabetes for the past ten years. she was admitted.B12 deficiency anemia. Patient has not suffered from any infectious disease previously. She is under strict dietary control. On November 2009. She was kept in CCU for two weeks in unconscious state. 2. no known complications. Once her condition improved. patient was admitted once again due to acute haemorrhagic gastroenteritis. the incident happened five years back. Regarding the past admission for AMI. Aspirin 150mg once daily Past Medical History: Patient was previously admitted 5 years back with similar complaints and was diagnosed with acute myocardial infarction. She is also diabetic and hypertensive.
She has been taking beta blockers (Carvedilol) for hypertension. Dietary history: Patient consumes normal Indian diet on a daily basis. Her mother died of old age 4 years back. She is aware of low and high blood sugar and ensures she does not consume excessive sugar. He used to be a driver as an oil palm estate. one died from motor vehicle accident. alcoholism or drug use. She has a general feeling of weakness 2. Systems Review: 1. Social History: Patient has done many jobs. Constitutional: Patient has been in good general health. age 51. Family history: Patient lives in a joint family consisting of 28 members living in the same house. She has also been very adherent to low sugar diet. factory worker. Family medical history: Patient’s father died from an unknown infections while was still very young. including being a rubber tapper. Patient married at the age of 18. no fever. non-veg curry and vegetable side dish. Patient’s younger brother. HEENT: 5 . no recent weight change. She is currently living under the financial support of her eldest son. Her husband died 5 years back from tuberculosis. Patient is also a hypertensive for the past 15 years. Currently patient is prescribed with oral metformin tablets. She is the eldest member of the family. has diabetes and hypertension as well. The other 3 children and alive and healthy. Her meal consists of Parboiled rice.Vikkineshwaran SM complication from the disease. She is the eldest of six siblings. Her parents have all passed away. Patient had 4 children. 3 of which died at very young age while 2 are still alive and well to do. Patient’s brother died of developing gangrene due to uncontrolled diabetes at the age of 47. grass cutter and finally as a hospital cleaner and gardener before retiring at the age of 55. Patient has no history of smoking.
Emotional: denies history of anxiety or depression 10. Dermatology: no new rashes of pruritus 6 . or pneumonia 4. Cardiac: see HOPI 5. b. Nose: no epistaxis or obstruction e. deep vein thrombosis. Rheumatic: no history of gout. See PMH 7. Respiratory: History of TB exposure. gangrene. Gastrointestinal: History of acute gastroenteritis with diarrhoea in 2009 and acute haemorrhagic gastritis on 2012. Taking levothyroxine 13. wheezing. haemoptysis. pulmonary emboli. 12. or lupus. Eyes: has blurred vision and cataracts on left side c. asthma. Menopause since age 54. Genitourinary: No history of UTI. No history of tonsillitis or tonsillectomy 3. No history of pleurisy. aneurysm 6. cough. Vascular: No history of claudication. Endocrine: patient has hypothyroidism. No headaches . 8.B12 deficiency anemia on 2009 11. Neuromuscular: not known 9. rheumatic arthritis.Vikkineshwaran SM a. Ears: normal hearing d. Haematological: history of vit.
No masses. felt weakly. Tongue was pink and shiny. She complained of difficulty in breathing. fundi not well visualized due to possible presence of cataracts on the left side. respiration 24. No aortic bruit heard in abdomen Other Systems Eyes: extra ocular motions full. Tympanic membrane was present and intact Nose: No discharge. no additional sounds heard. radio-radial abnormality: pulse no detected on right side Generally a well-developed. Thyroid gland not palpable.Vikkineshwaran SM Physical Examination Vital Signs: Temperature 36. slightly obese. no parasternal heave or thrills Auscultation: 1st & 2nd heart sound softly/weakly. rises with inspiration. septum not deviated. Microhemorrhages were seen on right side. Precordial Examination: Chest inspection: Symmetrical. pupils equal round and reactive to light and accommodation. Neck: jugular venous pressure 2cm.2oC. Pulse 96 regular with no collapsing pulse. Lymph nodes: No adenopathy Spine: normal position. no obstruction. gross visual fields full to confrontation. Sclera was non-icteric. Mouth: No teeth. Normal gag reflex. no costovertebral tenderness 7 . blood pressure 180/100 lying down. mobile. nontender. normal and not raised. Uvula moves up in midline. conjunctiva clear. no ulcers were seen. elderly Indian woman sitting up in bed. no scars or implants Apex beat: Located in 4/5 mid-axillary line. no murmurs Lungs: basal crepitations on both side. breathing normally. Ears: Normal hearing.
flat. Extremities: skin warm and smooth No pitting oedema or clubbing nor cyanosis on both hands and legs Neurological: Awake. Liver edge. No masses. no bruits. Cerebellar: no tremors. Cranial nerves III-XII intact except for poor vision on left eye. patient moves all extremities. alert and fully oriented. Reflexes all present and symmetrical Pelvic: not done Pervaginal: not done 8 .Vikkineshwaran SM Abdomen: soft. kidney not felt. Sensory: Grossly normal to touch and pin prick. Motor: Strength not tested. Liver span 10cm by percussion. Nontender to palpation. bowel sounds present. spleen.
ECG 2. ECG Patients ECG from admission till discharged are collected and analysed. Cardiac Enzymes and Renal profile 1. On overall.Vikkineshwaran SM Investigations and Results 1. evidence of Left bundle block was noted. Chest X-Ray 3. Patient also seems to have infraction on the left side of the heart. 9 .
P wave absent from V1 to V3. Left axis deviation (QRS upwards in I and downward in III). II shows an abnormal wave Interpretation: Left axis deviation indicates abnormal cardiac function while absence of p wave in V1 to V3 may indicate atrial fibrillation. P wave present from V4 to V6. 10 . rate regular.Vikkineshwaran SM ECG 1: Observation: ECG taken during triage admission. SA nodal block or junctional rhythm. HR ~60bmp (normal).
possibility of infarction on the left side. T wave dipping in V leads Interpretation: Slight improvement in heart rate. HR ~ 75bmp. regular rhythm. left bundle branch block 11 . abnormal ST segment depression from V4 to V6. left axis deviation. inverted p wave in V1.Vikkineshwaran SM ECG 2: Observation: ECG taken 1 hour after admission.
HR ~ 75bmp. Increased amplitude of R wave. Chest leads show increased QRS interval Interpretation: Left bundle branch block. normal sinus rhythm. ST segment absent in V1 to V3. Prolonged St segment in V5&V6. possibility of infarction 12 . left axis deviation.Vikkineshwaran SM ECG 3: Observation: ECG taken 2 hours after admission. V2 &V3 no p wave.
P wave negative in V1 indicates left atrial enlargement 13 . HR 61bmp. regular rhythm. M shape seen in R wave. p wave negative in V1 Interpretation: M shape in R wave indicates left bundle branch block. T wave dipping from V4 to V6.Vikkineshwaran SM ECG 4: Observation: ECG taken after patient admitted to ward (4hours post admission).
M shaped R wave.Vikkineshwaran SM ECG 5: Observation: ECG taken in ward on second day of admission. and III. II. left axis deviation. Patient had an acute onset of chest pain. 14 . After taking ECG. she was transferred to CCU. prolonged TP interval Interpretation: Sinus arrhythmia (bradycardia). Prolonged TP interval signifies increased isoelectric interval meaning decreased heart activity. Left bundle branch block. R wave decreased amplitude in I. rhythm irregular with bradycardia. HR 51bmp. Poor R wave progression highly specific for an infarction.
M shape present in I.Vikkineshwaran SM ECG 6: Observation: ECG taken in CCU after being monitored for about 10 hours. and left bundle branch block 15 . decreased TP interval. III. HR 60bmp. and AVF. AVL. R wave progression increased. T wave dipping. T wave absent in V1 to V3 Interpretation: Sinus rhythm with sinus arrhythmia.
Vikkineshwaran SM ECG 7: Observation: ECG taken after about 24 hour observation in CCU. abnormal Q wave in III Interpretation: Abnormal Q wave indicates cardiac pathology. M shaped R wave in I. increased R wave dipping in V1 to V3. irregular rhythm. left bundle branch block and left side infarction 16 . Left axis deviation. AVL and AVF. sinus bradycardia. HR 51bmp. patient’s condition improved and was transferred back to normal ward.
Chest X-Ray 17 .Vikkineshwaran SM Based on all the above ECG’s it is noted that the patient has possible non ST elevation myocardial infarction. 2. She also has left bundle branch block and left atrial hypertrophy.
Cardiac Enzymes and Renal Profile Cardiac Enzymes Enzyme & normal Day Day Day value (μ/L unless 1 2 3 stated) LDH (135-220) 224 767 150 AST (5-34) 27 48 14 CK (29-168) 52 65 29 Troponin I (>2ug/L) .Vikkineshwaran SM Observation: This is a PA erect chest X-ray taken on the day of admission. Lungs appear normal. All bones appear normal. Gastric bubble is absent. No lymph node enlargement. Right side diaphragm appears more raised than left. 506u g/L Observation: LDH: increased on day 1 and 2 while decreased on day 3 AST: normal on day 1 and 3 while increase on day 2 CK: normal on all 3 days Troponin I: decreased Interpretation: 18 . with fine lines seen on right basal side. Interpretation: Cardiomegaly is seen with hypertrophy of the left side. Lung airway is normal. and occupies more than half the chest width. Cardiac silhouette is noted. Upper zone vessel enlargement. Edges of the heart show shadowing. Underexposure and rotation is noted. Costophrenic angle present. No instrumentation is seen. 3. Lung fields are asymmetrical.
Renal Profile Values (mmol/L unless Day 2 Day 3 stated) Urea (2.7) 7.0 - Creatinine (50-98) 92. This shows her condition has improved. Patient’s cardiac enzymes are all within normal range on day 3. This indicates patient might have had an acute attack on this day.0 Observation: Urea: increased on day 2.0 6.9 3.(98-107) 107. Patient’s cardiac enzymes show an elevation in day 2.7 111.5-6.4 Sodium (136-145) 134 137 K+ (3. Increased LDH and AST is not specific for cardiac dysfunction although does indicate presence of heart cell damage. normal on day 3 Sodium: normal Potassium: normal Chloride: normal 19 .Vikkineshwaran SM Negative CK and Troponin with ST depression on ECG indicates this is myocardial ischemia.1) 3.7 Cl.5-5.
Hence she is diagnosed with Acute Myocardial Infarction.Vikkineshwaran SM Creatinine: increase on day 3 Interpretation: Increased urea and creatinine generally indicates poor renal function. Since the day of admission. had severe chest pain for about 30 minutes while warded on day 2 and she also had abnormal ECG findings. Severe chest pain lasting more than 20mins ii. the abnormality observed can be side effect of medication used. When she was pain free and stable. progress and Follow-up plan Madam A. Diagnosis In order to diagnose any patient with acute myocardial infarction. 20 . Elevated Cardiac enzymes Madam A. she was transferred back to medical ward. As patient did not show any symptoms of renal dysfunction. Abnormal ECG iii. was managed in Coronary Care Unit (CCU) with continuous monitoring for 24 hours. Management. at least two out of the three following criteria’s must be fulfilled: i.
the patient appeared alert. On physical examination. a 69 year old Indian woman is diagnosed with Non ST elevation MI/ unstable angina. pain 21 . Conclusion and Summary Madam A. She was treated with aspirin. She was discharged on the fourth day with the following medications: • Atorvastatin: anti-hypertensive • Amlodipine: Calcium Channel Blocker • Losartan: Angiotensin 2 Receptor Blocker • Metoprolol: selective β1 blocker • Isosorbide dinitrate: vasodilator for angina • Arixtra: Factor Xa inhibitor (anticoagulant) • Aspirin: analgesic • Clopidogrel: blood thinner • L. Thyroxine: T4 hypothyroidism Madam A was asked to come for follow up the following week. Patient had not pedal or sacral edema. The apex beat was deviated and weak heart sounds was heard. She was slightly overweight. She was also provided with a referral letter to Institute Jantung Negara to get her complete cardiac assessment done. Basal crepitations were also present.Vikkineshwaran SM patient has been under ccontinuous monitoring for 3 days. She was transferred to medical ward on day 3. She has a history of myocardial infarction 5 year back and is a diabetic and hypertensive. She had not clubbing or cyanosis. She developed acute chest pain on day 2 of admission and was placed under CCU care for 24hr continuous monitoring. conscious and responsive.
Corne. Harrison's Manual of Medicine. 3. She was under inpatient care and got discharged on the fourth day. 2010. ace inhibitors and several other medications. 18. Chest X-Ray Made Easy. Print. 22 . Print.844. 2013. Longo. United States: McGraw-Hill. Jonathan. References 1. Corne. Dan L. 3. beta blockers. London: Churchill Livingstone. 2010. 2. 3. Jonathan. Print. ECG Made Easy.Vikkineshwaran SM relief medication. Pg. London: Churchill Livingstone.
Vikkineshwaran SM Appendix 1. Cornell Medical Index (System’s review) 2. Patient Consent Form 23 .
Vikkineshwaran SM 24 .
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.