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1.      Sarawak Handbook of Medical
Emergency, 3rd Edition

Reference

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From
psychological aspect, he accepted the fact that he had heart disease and needed
further investigations. However, he did not family support as his family were
at Indonesia. This points that leads him to decide to be referred to Indonesian
Hospital as he could received family support and good for his mental health.
Thus, will help him in better prognosis of his illness

 

For
this patient, he already confirmed to have Myocardial infarction with
hyperlipidaemia. Hyperlipidaemia can leads to coronary artery disease where
formation of atherosclerosis plaque that occluded the coronary artery that
leads to Myocardial ischemia and ended up with Myocardial infarction. However,
the investigations that needed to confirm the occlusion of the coronary artery
of the heart is coronary angiography. This patient had problem to proceed with
the procedure as his company did not cover the procedure bills. Other of the
hospital bills usch admission bills and medication were covered by the company
insurance. This patient keen to be transferred to Indonesian Hospital as his
family were livimg there

 

A
part of the IV Streptokinase, the treatment also includes antithrombotic agents
such as oral Aspirin as it is significantly reduced mortality. Besides that,
ACE inhibitors also given o Myocardial infarction patient. Furthermore, the
treatment also includes statin which is to control the level of lipid where it
is the risk factor of occlusion of the 
coronary artery where by it leads to another attack of Myocardial
infarction of the heart

 

 

 

After
giving IV Streptokinase, it is important to watch out the complications of the
antithrombotic agents.This is including hypotension during infusion, allergic
reaction, uncontrollable bleeding and reperfusion arrhythmia. After reperfusion
therapy, patient’s PTT and fibrinogen level needed to be monitored to prevent
further episodes of uncontrollable bleeding. Reperfusion arrhythmia is actually
non-dangerous and it is actually a good sign for a successful reperfusion
therapy

 

The
duration between onset of the chest pain and time of treatment is very crucial.
Definitive management of Myocardial infarction is the reperfusion therapy, IV
Streptokinase. However, there was indications to give the reperfusion therapy.
Firstly, clinical symptoms suggest Myocardial infarction, secondly, ECG reading
reveal ST Elevation and thirdly, the onset is less than 12 hours. This
reperfusion therapy is actually antithrombotic agent which is preventing any
further formation of thrombosis.

 

It
is important in history to rule out congestive heart disease as the coronary
artery disease can leads to heart failure and the presentation could be acute
heart failure. Fortunately, this patient had no history of orthopnoea,
paroxysmal nocturnal dyspnea and from physical examination also reveal no sign
of heart failure such as pulmonary edema for left sided heart failure and
piting edema, hepatosplenomegaly for the right sided heart failure.

 

The
most likely reason of him to have Myocardial infarction is due to coronary
artery disease which is a sequale from the hyperlipidaemia. Hyperlipidaemia is
the state of excessive cholesterol level in the body that leads formation of
atherosclerosis plaque in the blood vessel, this plaque especially in the
coronary artery will cause obstruction and limited blood supply to the heart,
which is leads Myocardial ischemia and ended up with Myocardial infarction,
Myocardial infarction is the necrosis or death of the Myocardium cell of the
heart

 

For
the risk factor, from the history that he was a chronic smoker whereby he smoke
for 17 years but claimed to be occasional smoker as he smoke only once per
week. Being male also a risk factor for coronary artery disease that leads
Myocardial ischaemia and proceeded to Myocardial infarction. He was newly diagnosed
with hyperlipidaemia which is a risk factor to Myocardial infarction.
Fortunately, he had no medical illness such as Diabetes mellitus and
hypertension

 

Mr
sumarno, 36 years old, presented with crushing and dull epigastric pain
followed by left sided chest pain associated with nausea, vomiting, diaphoresis
and palpitations. Despite the epigastric pain, this is the typical symptoms of
Myocardial infarction. It is important to distinguish between unstable angina
with Myocardial infarction from the symptoms because the management would be
slightly different. Best explained in this patient, he had chest pain that not
subsided after rest which is not equal to unstable angina

Discussion

 

 

 

 

 

·        
He
was planned for coronary angiography. However, the insurance of his company did
not cover for the procedure bills, so he keen to be referred to Indonesian
Hospital

·        
In
the ward, monitoring of vital signs was done as well as monitoring of any occurrence
of chest pain

·        
The
reperfusion therapy was successful as resolution of ST Elevation more than 50%
and cessation of pain and after that, he was admitted in the ward

·        
He
also started on antithrombotic (oral Aspirin 300mg as bolus followed by 75 mg
daily ), Statin (atorvastatin 40mg daily), anticoagulant (Fondaparinux) and ACE
inhibitors (Perindopril 8mg daily)

·        
Once
ECG revealed ST Elevation and the onset of chest pain is less than 12 hours, he
was started on IV Streptokinase (1.5 megaunit in 100 ml Normal Saline), given
for 60 minutes. This is the reperfusion therapy

·        
Blood
was taken for investigations

·        
Upon
arrival to the Emergency department, the airway, breathing and circulation was
secured. IV line was put on as well as ECG monitoring was carried out to the
patient

Management

 

Impression:
this revealed the patient did not had Diabetes Mellitus

Hba1c:
5.4% (NORMAL)

Fasting
Blood glucose: 5.06 mmol/L (NORMAL)

Results:

Aim:
to rule out diagnosis of Diabetes Mellitus

Fasting blood
glucose and Hba1c

 

Impression
: this revealed this patient had newly diagnosised dyslipidaemia

 

Component

Value

Comment

Cholesterol

8.14
mmol/L

Increased

Triglycerides

1.84
mmol/l

Increased

LDL
Cholesterol

6.13
mmol/l

Increased

HDL
Cholesterol

1.17
mmol/l

Normal

Results:

Aim:
to rule out diagnosis of hyperlipidaemia

Lipid profile

 

Impression:
he had mild hyponatraemia. Otherwise, other parameter was normal

 

Component

Value

Comment

Urea

4.6
mmol/L

Normal

Sodium

132
mmol/l

Decreased

Potassium

5.0
mmol/l

Normal

Creatinine

109
mmol/l

Normal

Result:

Aim:
to look sign of renal impairment and electrolyte imbalance

Renal profile

 

Impression:
There was sign of infection evidenced by leucocytosis where the neutrophils
were predominantly increased, suggesting bacterial infection

 

Component

Value

Comment

Haemoglobin

16.0
g/dl

Normal

White
blood cell

23.5
X 10^9 /L

Increased

Haematocrit

46.0
%.

Normal

Platelet

284
X10^9/L

Normal

Lymphocyte

1%

Decreased

Neutrophills

96%

Increased

Result:

Aim
: to look for sign of infection

Full blood count

 

Thus,
this support the diagnosis of Myocardial Infarction

Result
:    Creatine Kinase (CK) – 4517 U/L-
INCREASED

Aim:
to look sign of Myocardial infarction

Cardiac Marker (CK)

 

Thus,
this patient had Myocardial infarction with ST Elevation (STEMI)

The
Electrocardiogram (ECG) reveal ST Elevation at lead aVL, V1-V3

Results:

Aim:
To look for sign of ST Elevation

Electrocardiogram
(ECG)

Investigations

 

 

 

·        
There
was no complaint of retrosternal burning sensation

Points
against

·        
Initial
onset of the symptoms was epigastric pain

Points
for

Gastro-esophageal
reflux disease

Differential
diagnosis

 

·        
He
was  a chronic smoker since 19 years

·        
Numbness
at jaw and left shoulder and arm

·        
It
was associated with nausea, vomiting, palpitations as well as diaphoresis

·        
History
of left sided chest pain that dull & crushing in nature and  it was not relieved by rest

Points
for

Acute Myocardial
Infarction

Provisional
Diagnosis

 

Mr
Sumarno, 36 years old, Indonesian presented with dull & crushing chest pain
that not relieved by rest, associated with numbness of jaw and left shoulder
and arm. He also had nausea, vomiting, palpitations and diaphoresis during the
attack. The onset between chest pain and arrival to ED was 15 minutes. He was a
chronic smoker since 19 years old. Physical examination revealed normal
findings

Summary

 

There
was no significant findings in the system examinations

Abdominal and  central nervous system examination

 

On
Auscultation, the breath sound was vesicular, normal and equal intensity
bilaterally. There was no added breath sounds. Vocal resonance was normal

Percussion
revealed resonant all over lungs area

On
palpations, the trachea was centrally located without any trachea tug. The
chest expansion was equal bilaterally

On
inspection, there was no chest deformity or barrel-shaped chest noted. The
chest moves symmetrically with respiration. There was no accessory muscle used
and no indrawing of costal margin or intercostal spaces.

Respiratory system
examination

 

 

 

 

There
was no pitting edema, no hepatosplenomegaly

On
Auscultation, the first and second heart sounds were present and normal. There
was no added heart sound or murmur heard.

On
palpation, all peripheral pulses were present. The apex beat located at 5th
intercostal midclavicular line. There was no palpable murmur or parasternal
heave

On
inspection, the JVP was not raised from sterna angle. Apex was not visible.
There was no surgical scar, precordial bulge, dilated veins or extra pulsation
noted

Cardiovascular
system examination

 

Temperature:
37.5°C (Normal)

Blood
pressure:119/79 mmHg

Pulse
rate : 80 beats per minutes (Normal)

Respiratory
rate : 20 breaths per minutes (Normal)

Vital signs

 

He
was conscious, looked well, pink in color and not in pain. He was comfortably
lying supine on the bed. On hands, there was no clubbing and sign of infective
endocarditis such as osler node, janeway lesion and splinter haemorrhage as
well as normal capillary refill time. The pulse rate was 80 beats per minute
with normal rhythm and volume. There was no radio-radial delay and
radio-femoral delay.  Collapsing pulse
was negative. On face, there was no conjunctiva pallor ,sclera jaundice and no
central cyanosis.

General Examination

Physical
Examination

 

He
was married and blessed with two children. His wife and children were living in
Indonesia while he was living in Bangi, Malaysia with workmates in an
apartment. The apartment house at floor 3 and there was no lift available.
However, he had no problem to climb stairs in daily basis. The financial
support for his family fully funded by him as his wife was housewife. The
current hospital bills was covered by company insurance. However, there was an
issue as he was unable to proceed with angiogram procedure as the company
insurance did not cover for hospital bills exceeding rm30K. He planned to do
the angiogram procedure in Indonesia. He was a chronic smoker since 19 years
but claimed to be occasional smoker as he smoke only once per week. He was an
alcoholic drinker and currently are not which the last alcohol consumption when
he was 20 years old.

Social history

 

 

 

His
father, 60 years old, worked as farmer while his mother, 58 years old worked as
retailer. He was the last child of three siblings. His mother has hypertension
and hyperlipidaemia. There was no history of heart disease in the family

Family history

 

He
had drug allergy of Paracetamol as he will developed generalized rashes after
consumption

He
was not on any drugs before

Drug and allergy
history

 

He
had no significant surgical history

Surgical history

 

This
is his first hospitalization. He had no underlying medical illness such
hypertension, hyperlipidaemia, diabetes mellitus and others

Medical history

 

Otherwise,
there was no complaint of fever, cough, shortness of breath, retrosternal burning
sensation and no history of orthopnoea and paroxysmal nocturnal dyspnea. On
further questioning, he was a chronic smoker since 19 years old but claimed to
occasional smoker as he smoke only once per week. He did not had medical
illness such as hypertension, hyperlipidaemia and diabetes mellitus and no
family history of heart disease as well as no recent history of  heavy lifting and  history of immobilisation

It
also associated with nausea and vomiting as well as palpitation and
diaphoresis. After that, he took rest while sitting. However, the pain did not
subside but gradually increased in intensity. Then, he was brought to private
clinics for medical attention and referred to Emergency department of Hospital
Serdang. The onset of pain to arrival to the Emergency department of Hospital
Serdang was 15 minutes

On
the day of admission, during working time when he was walking, he developed
epigastric pain. It was sudden and the nature was dull & crushing pain. It
radiates to left sided chest and associated with numbness at his jaw and left
shoulder and arm. He rated the pain in severity 5/10 and gradually increased
intensity up to 7/10

History of
presenting illness

 

Mr
Sumarno, 36 years old Indonesian gentlemen , factory worker and chronic smoker
came to Emergency department with complaint of chest pain

Chief complaint

 

 

 

 

 

 

 

 

 

 

Superior:
Prof Wan Aliaa Wan Sulaiman

Matrics:
170625

Name
: Lahajang Bin Abdul Mutalib

 

 

 

Acute
Myocardial infarction

Case
write up 1

Year
5

Senior
Medical Posting

 

Fakulti
perubatan dan Sains kesihatan

UNIVERSITY
PUTRA MALAYSIA

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