CASE STUDY I

Observation of a case in Emergency Department for Diagnosis & Management

Presented By

Ahmed Usama Ahmed El-Masry

Under Supervision of

Dr. Kareema

…………………………

2014-2015
SUEZ CANAL UNIVERSITIY
Faculty of Medicine
Emergency Department
 Case Study I
History
Personal History:
Mr Hanafi Abbas Mahmoud is a 51 years old male patient living in El Tall El Kabeer
in a rural area. He is married 25 years ago and has 3 siblings, the youngest of which
is 8 years old.
He is working as a Tailor in a clothes Factory.
He is a heavy Shisha Smoker for over 20 years (3-4 times daily), no Drug abuse & no
Alcohol Intake.

Complaint:
The patient came complaining of Chest Pain lasting for 2 hours duration.

History of present illness:

The patient is known to be diabetic, which was discovered accidentally 5 years ago,
and since then he is receiving oral hypoglycaemic drugs.

The patient condition started 3 years ago when he had similar attacks of chest pain
that occurred repeatedly despite receiving sublingual Nitro glycerine tablets so the
patient had a coronary stent operation one year ago which gave him much relief.

2 hours ago, the patient had severe retrosternal pain that he was not able to perform
his job. It started with sudden onset and intermittent course in which there have been
3 attacks of pain each lasting for 5 – 10 minutes with intervals of partial relief lasting
for 30 to 45 minutes.
The pain was described as chest compression in the retrosternal area radiating to the
left subscapular region & to the left shoulder.
It was aggravated by exertion and relieved partially by nitro glycerine tablets and
rest.
It was associated with shortness of breath and blurring of vision.

The patient does not complain of hypertension and there is no history of syncope,
palpitation, bluish discoloration of peripheries or lower limb oedema.

The pain is not aggravated by chest movement and not relieved by changing posture
excluding musculoskeletal causes of pain.
There is no cough, haemoptysis, or audible breathing sounds excluding respiratory
causes of pain.
There is no history of dysphagia, odynophagia, hematemesis or heartburn excluding
oesophageal causes of pain.
There is no history of chest trauma excluding traumatic causes of pain (fractured rib,
lung contusion … etc.)

Past History
The patient had similar attacks 2 years ago, that stopped after having a coronary stent
operation.
The patient received 3 nitro-glycerine tablets before hospital admission
He is on regular use of aspirin (300 mg / day), oral hypoglycaemic drugs and Insulin
injections.
The patient is not complaining of any allergy.
He did not receive any types of food before admission.
He did not receive sildenafil in the last 8 hours.
He does not complain of liver, kidney or blood diseases.

Examination
1ry Survey:
Airway:
The patient has patent airways (he is speaking well)
There is no Cervical Spine Fracture (no history of trauma)
Breathing:
By Inspection, the Respiratory Rate is 14 breathes / minute, there is
symmetrical chest movements and there is no chest deformity.
By Palpation, There is no chest tenderness, there is symmetrical chest
expansion & there is no shifting of trachea.
By Percussion, No Hyper-resonance
By Auscultation, No Abnormal Breathing sounds.
Circulation:
Central Pulsation is felt, central to peripheral pulsation is comparable &
peripheral-to-peripheral pulsation is also comparable.
Radial pulsation is 63 beats per min, regular, of average volume,
symmetrical in both sides and has no special characters.
Blood Pressure: 115 / 85 mmHg (Normal)
Capillary Filling time: less than 2 seconds.
Disability:
The Patient is Alert on AVPU Score.
 The pupils are rounded, central, responsive to light & equal on both
sides.
Exposure:
No head, Neck or Spine findings.
Cardiac Examination
By inspection:
There is no skin redness, pigmentation, ulceration, fistulae or
scars.
Respiration is abdomenothoracic.
No visible pulsation at the apex of the heart.
By Palpation:
Palpable pulsation of the heart at the fifth intercostal space in the
midclavicular line.
There are no masses, swellings, tenderness or pulsating masses.
By Auscultation:
No abnormal cardiac sounds, muffling or murmurs were heard at
the apex of the heart, xiphisternal area and aortic areas.
No Chest, Abdominal, upper limb or lower limb Findings.

No other symptoms or signs suggesting other system affection.

Differential Diagnosis
1. Acute Coronary Syndrome (most probable)
2. Pericarditis excluded by absence of localized friction rub over pericardium.
3. Aortic Dissection excluded by absence of unequal pulsation or pulsating
masses.
4. Musculoskeletal Pain excluded by not being aggravated by chest movement
and not being relieved by changing posture.
5. Pleurisy, Bronchitis, Broncho-Pneumonia or Lung Carcinoma excluded by
absence of cough, haemoptysis, friction rub on the chest and audible abnormal
breathing sounds.
6. Esophagitis or peptic ulcer excluded by absence of history of dysphagia,
odynophagia, hematemesis or heartburn.

Provisional Diagnosis
A 51 years old male diabetic patient came complaining of intermittent retrosternal
sever chest tightness, radiating to the left subscapular region & to the left shoulder for
2 hours duration most probably caused by non-Stable Angina Pectoris not
complicated.
 Management
The patient should be admitted and have the following investigations:
1. 12 Leads ECG for any abnormal findings including T-wave inversion or ST
segment elevation.
2. Cardiac enzymes (Myoglobin, Troponin I and CK MB.)
3. Chest X ray (for exclusion of trauma, pulmonary conditions & aortic
aneurysm).

The patient should receive:

1. Aspirin 300 mg for chewing (to prevent propagation of the thrombus)
2. Oxygen inhalation session (5-10 Litres / minute)
3. Nitro glycerine 10 mg sublingual tablets (for coronary vasodilatation) >> ask
1st about intake of sildenafil.
4. Morphine 5-10 mg IV (for relieving pain)

If the patient’s condition improved he should be put under observation for 24 hours.
Drugs taken after stabilization of the condition:
5. Heparin SC injection (to prevent new thrombus formation)
6. Glycoprotein IIb & IIIa inhibitors.
7. Beta Blockers to decrease cardiac demands
8. Diltiazim (if beta blockers are contraindicated, e.g. Asthma)

If the patient’s condition didn’t improve or MI was present

9. Primary PCI within 90 minutes (if available)
10.Thrombolytics if PCI is not available (unless absolutely Contraindicated)