AIPACAA

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PATIENT REPORT HISTORY PATIENT PARTICULARS
NAME JAFARI SAID HASANI AGE 57 YEARS SEXMALE
ADRESS TEGETA TRIBE PARE OCCUPATION
BUSINESSMAN RELIGION MUSLIM EDUCATION LEVEL
CLASS SEVEN MARITAL STATUS MARRIED NEXT OF
KIN WIFE
DATE OF ADMISSION DATE OF CLERKSHIP INFORMANT
Patient
14/11/2023 15/11/ 2023
NUMBER OF DAYS IN THE WARD 1 CHEF
COMPLAINT CHEST PAIN 3/7 AWARENESS OF HEARTBEAT
1/7 HISTORY OF PRESENTING ILLNESS The patient
was apparently well until 3 days prior to
admission when the patient experienced central
chest pain which was of sudden onset, tightening
in nature, radiating to the left shoulder and
neck. It had no specific periodicity, associated
with shortness of breath and fatigue. It was
aggravated by exercise and It was not relieved by
resting. Also, the patient complained of
awareness of heartbeat which was of suddenly
onset, progressive with no specific time
periodicity. It had no associating factors, It
had no aggravating factors and no relieving
factors. however, the patient denies history of
difficulty in breathing, lower limb swelling or,
ankle swelling
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• REVIEW OF OTHER SYSTEMS
• RESPIRATORY SYSTEM
• No wheezing
• No cough
• No Sputum production
• GASTROINTESTINAL SYSTEM
• No hx of vomiting No hx of nausea
• No hx of difficulty in swallowing No hx of
  painful swallowing
• No hx of abdominal pain
• No hx of abdominal swelling No hx of diarrhoea
• UROGENITAL SYSTEM

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The patient had no history of bone
infection. HAEMATOPOIETIC SYSTEM The patient had
no Easy bruising No Bleeding tendencies ENT
SYSTEM No history of abnormal discharge from ear
and nose. No history of pain at ears and no
history of sore throat. ENDOCRINE SYSTEM NO
history of Excessive urination no history of
excessive seating no history of cold
intolerance. No history of excessive
hunger INTEGUMENTARY SYSTEM No history of hair
loss No history of change in hair colour. No
history of itchy skin No history of pitting nails
and no separation from the nail beds and
transverse lines on the nails. PAST MEDICAL
HISTORY (PMH) He has no history of any other
chronic illness such as diabetes, hypertension,
COPD, SLE or cancer No history of prior
admissions no history of trauma/surgical
intervention. No History of blood
transfusions. No history of using herbal
medication No allergy to any Medication or
food FAMILY HISTORY No history of familial
illness in the family such as hypertension,
diabetes, sickle cell e.t.c No history of sudden
deaths in his family.
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SOCIAL HISTORY He is the first born in a family
of five children. His mother and father are
dead. Both died at their old ages His four
siblings are alive His wife is still alive and
health. They have four children who are alive and
healthy He used to smoke, but he stopped
smoking about 10 years ago No history of
alcohol he has no history of substance use such
as marijuana, heroin, cocaine, and
opioids DIETARY HISTORY He eats three meals a
day such as breakfast, lunch and dinner. His
breakfast consists of tea with bread or rice His
lunch mostly consists of ugali and green
vegetables His dinner consists of ugali and fish
or meat or green vegetables and fruits. He
drinks plenty of water about two liters per
day. he has a normal salt intake in food with no
addition of salt. SUMMARY 1 I have just
presented a 57 years old man with , retrosternal
chest pain and awareness of heartbeats. But had
No lower limb swelling No difficulty
breathing. PROVISIONAL DIAGNOSIS Acute coronary
syndrome (myocardial infarction ) Point
supporting Chest pain Radiates to the left
shoulder, and neck Differential diagnosis
Cardiac arrhythmias Point supporting awareness
of heartbeat
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Point against No shortness of breath

• PHYSICAL EXAMINATION
• GENERAL EXAMINATION
• The patient appears ill looking and looks
  somewhat anxious but is in no apparent distress.
• He had a cannula on his right arm. He was
  afebrile
• he had normal grayish Color of his hair, normal
  Texture, and Hair distribution. he had no
  subconjunctival pallor.
• he had no jaundice
• No angular stomatitis, no angular cheilitis or
  any lesion to to external part of his mouth. He
  had normal dental formula and no cavitations.
• His tongue had no central cyanosis his had no
  palpable lymph nodes
• He had no palm paler, no palmer erythema, no
  cyanosis.
• No yellowish nail, no koilonychia, no
  leukonychia, and normal capillary refill of 2
  seconds
• no splinter hemorrhage, no Janeway lesion, no
  oysters node, no finger crabbing and no duptyne
  contracture and no pedal, ankle and tibial edema
• VITAL SIGNS

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• d. Blood pressure. 132/84mmHg (at 45 degree
  supine position) at Korotkoff phase 1 to 5
• e. O2 saturation --98 in room air
• SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM
• Pulse Rate- the radial pulse of the right hand
  of a patient
• Rate-103 Beats per minute (bpm) (tachycardia)
• Rhythm regular
• Volume. strong
• Character normal
• Synchronicity synchronies with the left radial
  pulse
• Blood pressure. 139/84mmHg (at 45-degree supine
  position) at Korotkoff phase 1 to 5
• No abnormalities with pulsations of the neck such
  as the carotid artery or the jugular vein
• Juglar venous pressure was not elevated
• Precordial examination Inspection
• Normal chest contours.
• No traditional or surgical marks No precordial
  hyperactivity

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Auscultation S1 and S2 heart sounds were heard in
all valves at all auscultation area mitral,
tricuspid, aortic, and pulmonary No murmur No
crackles. Liver examination No hepatojugular
reflux. The liver was not enlarged and not
tender no cardiac liver Auscultation of the
base of the lung no basal crackles. RESPIRATORY
SYSTEM Inspection No abnormalities in chest
morphology with no deformity or swelling. No
abnormalities with chest wall movement Bilateral
symmetrical chest movement with respiration No
any therapeutic scar, no any surgical scar, No
use of accessory muscles on inspiration . Palpati
on Trachea is centrally located No Tenderness No
palpable mass No more tactile vocal fremitus
Normal bilateral chest expansion. Percussion Reso
nant percussion note. Auscultation normal
breath sounds No abnormalities in vocal
resonance. GASTROINTESTINAL SYSTEM
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Inspection No oral thrush, no atrophic glossitis
Normal dental formula Normal lever of the
abdomen flat and not distended No stretch marks
or traditional marks No surgical marks The
abdomen was bilateral symmetrical and moves with
respiration Umbilicus was inverted No distended
blood vessels. Palpation Superficial. There was
no tenderness on the umbilical region. No mass
palpable Soft abdomen on palpation No abdominal
guarding during superficial palpation of the
abdomen. Deep. There was no tenderness on the
umbilical region. No mass palpable. Soft abdomen
on palpation. No abdominal guarding during deep
palpation of the abdomen. The spleen was not
palpable. The left kidney was not palpable. The
liver was not enlarged. The right kidney was not
palpable.
Percussion Tympanic note was heard Auscultation N
ormal bowel sound was heard
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NERVOUS SYSTEM CNS Higher centers The patient
was conscious with Glasgow Coma Scale of 15/15
The patient was oriented to time place and
person. The patient was fluent in speech Both
long and short-term memories were intact.
Organization, concentration, and attention were
also intact. Cranial nerves The patient smells
normal -CN1(olfactory nerve) Visual acuity, color
vision, light perception and Visual feed were
normal. - CNII (optic nerve) Patient could move
eye balls on various sides- CNIII, IV, VI
(oculomotor. Trochlear and abducens
nerve) Patient could chew normally- CN V
(trigeminal nerve) Patient could smile and
blink- CNVII (facial nerve) Both Rinne and Webber
test were normal CNVIII (vestibulocochlear
nerve) he could swallow normally- CN IX
(glossopharyngeal nerve) Patient was able to
shrug shoulder CNXI (accessory nerve) Patient
could protrude his tongue- CNXII (hypoglossal
nerve) PERIPHERAL NERVOUS SYSTEM PNS Motor
system Muscle bulkiness- Normal on both left and
right Involuntary movements- absent Power- 5/5
Tone- hypotonia Reflexes
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Normal deep and superficial reflexes coordination
Was normal in both upper and lower Babinski
sign was negative Sensory system Lateral
spinothalamic tract pain and temperature are all
normal Anterior spinothalamic tract crude touch
and pressure sensation are all normal Dorsal
column vibration, fine touch, two-point
discrimination and proprioception are all
well. Normal sense of Sharp pain Joint position
change SUMMARY 2 I have just presented Jafari
Saidi Hasani a 57 years old man with chest pain
and awareness of heart beats On physical
examination , he was afebrile and tachycardic
(103 bpm). But he had no pedal, ankle and tibial
edema There are no murmurs or apical prominence.
There was no peripheral edema.
No other remarkable findings PROVISIONAL
DIAGNOSIS Acute coronary syndrome (myocardial
infarction ) Point supporting Chest pain
Radiates to the left shoulder, and
neck DIFFERENTIAL DIAGNOSIS Cardiac
arrhythmias Point supporting awareness of
heartbeats and tachycardia MANAGEMENT PLAN
(INVESTIGATION AND TREATMENT) INVESTIGATIONS
DONE IN WARD 1. Full Blood Picture. (FBP) normal
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• 2. Lipid profile
• Total cholesterol 255 mg/dl Normal range
  150-250 mg/dl
• Triglycerides 100 mg/dl Normal range 75-165
  mg/dl
• Phospholipids 315 mg/dl Normal range 150-380
  mg/dl
• HDL 24 mg/dl
• Normal range 34-69 mg/dl
• LDL 113 mg/dl
• Normal range105-180 mg/dl
• Serum electrolytes hyponatremia and hypokalemia
  were present
• ECG Normal
• Cardiac biomarkers troponin slightly elevated
• INVESTIGATIONS THAT SHOULDVE BEEN ADDED
• Coronary Angiography Invasive procedure using
  contrast dye and X-rays to visualize the
  coronary arteries, identifying blockages or
  narrowed areas.
• Echocardiography serves to assess cardiac
  function, detect coronary artery disease,
  evaluate valve function, measure ejection
  fraction, monitor changes over time, and
  identify structural abnormalities

• TREATMENT
• Glyceryl trinitrate sub-lingual 0.5mgIV
• IV opiates initially morphine sulphate 510mg or
  diamorphine 2.55 mg)
• Aspirin oral dose of 300mg first tablet within
  the . First 12 hour, followed by 75 mg . Aspirin
  clopidogrel 600 mg early (within 12 Hours).
• Atorvastatin (PO) 80mg stat then 40mg 24hourly
• Heparin UFH (IV) 70-100U/Kg body weight a 24hourly

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