Case 2- Stable Angina

Date of admission: 11/3/14, Date of clerking: 12/3/14
Mr. Muniyapan is a 51 year old Indian gentleman with a history of dyslipidemia presented with right sided chest pain for 30minutes prior to admission. On the day of admission, patient developed the chest pain while driving a lorry. It was sudden onset, crushing in nature and radiated to the left side of chest. It was not relieved by rest. Pain score was 6/10. There was no associated symptoms such as profuse sweating, shortness of breath, palpitations, nausea or vomiting, paroxysmal nocturnal dyspnea or orthopnea. This was his 1st episode. Patient claimed that he was diagnosed with dyslipidemia 3 years ago but defaulted follow up and non-compliant to medication since his supply finished. He does not have hypertension or diabetes mellitus.
His mother is a hypertensive and diabetic patient. Otherwise, there is no significant family history.
He is a non-smoker and a social drinker.

On examination
Patient was comfortable, no complains of chest pain. Patient was not tachypneic.
BP: 113/71
PR: 69
RR: 16
T: afebrile

CVS: apex beat not deviated, no thrills, S1, S2 heard, no murmurs
Respi: Lungs were clear, air entry equal, no added sounds such as crepitations.

Other systemic examinations were not remarkable.

Management on Admission:
Patient was treated with :
1. T Aspirin 150mg OD
2. T. Plavix 75mg OD
3. S/L GTN 1/1 PRN
4. Oxygen Supplementation 3L O2 on nasal prong

1. ECG upon admission was done and was noted to have ST elevation lead II(1 small box), III, aVF (2 small box) ST depression at lead 1, aVL.

1 hour later, another ECG was done and the ST elevation readings were noted to have resolved spontaneously.
2 hours later, a repeated ECG revealed the same findings, however there was a T wave inversion in lead II, III, aVF.
Cardiac Troponin was done: 0.77
Provisional Diagnosis: NSTEMI

Continued management:

1. T. Simvastatin 40mg ON
2. S/C Fondaparinux 2.5mg Stat and BD
3. T. ISMN 30mg ON
4. IV Ranitidine 50mg TDS
5. Complete rest in bed
6. Standby ECG if chest pain noted.

(Investigations incl FBC, RP, LFT, all were within normal parameters)

Progress Notes
Day 2-12/3/2014

Patient complained of central chest pain at 8.40am. A S/L GTN 1/1 Stat was given. The pain resolved after 20minutes. Otherwise, patient appeared comfortable and not in respiratory distress. He was tolerating orally. On examination, his vitals were normal and no other significant findings. He was started on T. Bisoprolol 1.25mg OD. The anti-coagulation medication was continued. The T. ISMN 30mg ON was changed to T. ISMN 30mg OD. He was planned for an ECHO and to continue complete rest in bed.

Day 3- 13/3/2014

Currently, patient appeared very comfortable and has not complain of chest pain for more than 24hours. On examination, vitals were normal and lungs were clear. He was seen by Dr. Tan and ECG on admission was noted to be non-significant. He was re-diagnosed as a stable angina and was allowed discharged to be followed-up at the KK in 1 month's time. A FSL and FBS was planned to be done after discharge.

*the revised diagnosed of stable angina was inappropriate.