PATIENT’S BIODATA:

Name : Zainal bin Aris

Age : 72
Race : Malay
Gender : Male
Nationality : Malaysian
Occupation : Ex-British army
Address : Kg. Melayu Ampang
Marital status : Married with 11 children
Date of admission : 14 June 2009
Date of clerking : 15 June 2009
Source of clerking : Patient

HISTORY
Chief complaint:
Mr Zainal presented with left-sided chest pain that lasting for 1 hour prior of
admission.
History of presenting illness:
Mr Zainal with a known case of hypertension for one month ago came to casualty at
10 pm with retrosternal chest pain. The pain started whiles he watching tv at around 9
pm and kept continuously worsening through out the 1 hour duration. He felt there
was stabbing pain at the left chest and the pain radiated to left shoulder towards left
scapula region.
During the attack, he was conscious and sweating. He also experienced palpitation
and generalized mild headache. Since 2 months ago he had non-productive cough and
was given antibiotic and expectorant from GP.
This was the first attack Mr Zainal experienced. He tried to relieve the pain by having
various sitting posture and walking. But the pain never stopped and worsened. He also
applied some traditional oil on the affected chest and no changes occurred.
The patient also denied experiencing dyspnea, orthopnea, paroxysmal nocturnal
dyspnea and syncopal attack.
He also noted there were no nausea, vomiting and abdominal pain. The passing urine
and bowel output were normal.
He put the severity scale 10/10 of the severe pain.

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Past Medical history:
Mr Zainal was diagnosed by having hypertension for one month ago and defaulted on
the antihypertensive drug (T. Amlodipine) 1 week later due to drowsiness.
He was also admitted to HUKM 1 year ago because of having urinary bladder calculi
secondary to Benign Prostatic Hyperplasia (BPH).
He also has chronic skin scaly lesion on the both arms and legs since 30 years ago.

Past surgical history:

Bladder calculi removal by surgery for 1 year ago.
In 1956 (53 years ago), he had undergone a surgical carbuncle removal on his lower
part of his left arm.

Family history:
The patient did not know the medical illness his parents had, since they are in
Indonesia and not much contact. His father had died in 1991 but his mother still alive.

Social history:
Mr Zainal is an ex-army since 1970. He is non-smoker and non-alcohol consumer. He
is married with 11 children. He lives with his wife in single storey bungalow house at
Kg Melayu Ampang.

Drug/medication history:
The patient does not know the name of antihypertensive drug he defaulted three
weeks ago.
He took traditional herbs medication.

Drug/ food allergies:

He felt drowsiness after taking 1 week duration of the antihypertensive drug.
No food allergies.

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PHYSICAL EXAMINATION
General examination
Upon general examination, the patient was alert and conscious lying on 45° bed. He
was not in respiratory distress and not cachexic. There was an iv line on his right arm
Vital signs: Blood Pressure : 101/78

Pulse Rate : 78
Respiratory Rate : 24
SPO2 : 100%
Specific examination
Hands:
Warm palms, no clubbing, no pallor, no stigmata of infective endocarditis, no tendon
xanthoma can be detected. The both palms also were not sweating. The pulse rate was
78 beats/ min in regular rhythm but bounding and good volume. No radio-radial delay
and no radio-femoral delay. When raising the patient’s hand, no collapsing pulse
presented.

Face:
No xanthelasma around the eyes but there were corneal arcus on both side of his
cornea suggestive of hypercholesterolemia. There were also no jaundice and
conjunctivae pallor. In the mouth, no central cyanosis can be seen, the hydration
status was normal and the oral hygiene was good.

Neck:
The JVP was not raised and the carotid bruit couldn’t be heard.

Chest:
On inspection, the chest was symmetrically normal, no scars and moved normally
with respiration.
Upon palpation, the apex beat was displaced from normal site to sixth intercostal
space, 1cm lateral to midclavicular line. No parasternal hieve and no thrills can be felt
for the all four valve areas.
While auscultation, the first and second heart sound can be heard normally and no
added sounds and murmurs.

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Legs:
No surgical scars can be seen but there were multiple raised small black nodules on
the both pretibial areas. The popliteal pulse and dorsalis pedis pulse of both legs were
in normal rhythm.
The patient also did not show any evidence of pedal oedema on both legs.

Summary:
Mr Zainal, 72 years old Malay man with a known case of hypertension presented with
retrosternal stabbing chest pain for 1 hour duration. From examination, the apex beat
was displaced from normal site. The provisional diagnosis is unstable angina.

PROVISIONAL DIAGNOSIS
UNSTABLE ANGINA
The patient has known case of hypertension for last one month which is one of risk
factors to get acute coronary syndrome especially in elderly man. Some investigations
can support the diagnosis:
1. In ECG, no ST-elevation, but T wave inversion suggestive of ischemia event.
There also first degree heart block in lead II which may complicate the acute
coronary syndrome.
2. The cardiac enzymes were not raised.
LDH 288 U/L (240-461U/L)
CKMB 54 U/L (24-170 U/L)
AST 35 U/L (0-40 U/L)
The cardiac enzymes were in normal range which suggestive it was not a
myocardial infarction.

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DIFFERENTIAL DIAGNOSIS
1. ACUTE MYOCARDIAL INFARCTION
Reason that can support this diagnosis was the chest pain lasted for 1 hour. But further
investigation did not show it was a myocardial infarction event (no ST elevation in
ECG and the cardiac enzymes were normal). The patient also claimed that after
admitted in casualty, he was treated with sublingual drug (GTN) and the pain stopped.
In MI, the pain cannot be relieved by GTN.

2. PNEUMONIA
The patient claimed that he had chronic unproductive cough since 2 month ago. In
examination there were bibasal minimal crepitations. In CXR, there were opacities of
lower zone in both lungs. But we concentrate more on the newly presented illness
with hypertension as a risk factor to develop acute coronary syndrome.

DISCUSSION
Myocardial ischemia results from imbalance between the supply of O2 to
cardiac muscle and the myocardial demand. While angina is a descriptive term for
chest pain arising from he heart as a result of myocardial ischemia. Duration should
usually last for less than 20 minutes. But further investigations are needed to support
it is an angina. The exacerbations factors are emotion either in anger or excitement.
Cold weather and post-prandial also can lead to angina attack.
In this patient, we also can perform resting ECG. It is normal between attack
while there would be ST depression and T inversion during the attack. In exercise
ECG, show signs of severe coronary artery disease if it shows deep ST- depression
and paradoxical fall in BP. This time, the physician can consider for coronary
angiography.
Basically the patient is treated symptomatically for pharmacological and non-
pharmacological aspect. So the early management involves are by giving high flow of
oxygen, morphine as analgesic and nitrates to dilate the coronary artery. Beta-
blockers are given to reduce the heart rate and force of ventricular contractions;
therefore, it can reduce the myocardial oxygen demand. Calcium channel blocker are

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used to relax the coronary artery contraction and to reduce the force of left ventricular
contraction.
While the non-pharmacological aspect involves the surgical part where the
angina persists or worsens in spite of general measures and optimal medical
treatment. The treatment involves coronary artery bypass graft. It is prognostic value
for patients with left main stem coronary stenosis and three vessel coronary disease as
well as poor left ventricular function. The other management is coronary angioplasty
where if there is suspected localized atheromatous lesions. The artery is dilated using
the small inflatable balloon or intracoronary stents