Summary 1

Mr SBS, a 50 year old Malay man, with no known medical illness, chronic smoker with 45 pack years of smoking history, presented to the Emergency Department of HTJ with complaints of sudden onset of central chest pain which came on during rest, was pressing in nature, non-radiating, not aggravated by movement and breathing, not affected by posture, not relieved by rest, pain score of 8/10, 5-6 episodes lasting about 15 minutes, associated with sweating, palpitations, nausea, shortness of breath and dizziness which was preceded by severe generalized headache two days prior. He has had multiple episodes of chest pains preceded by severe headache in the past 4 years but did not seek any medications.

Question: What does his chest pain on presentation suggest to you? What does his "multiple episodes of chest pains preceded by severe headache in the past 4 years " suggest to you?

He was brought to a private GP by his wife after 1 hour of onset of chest pain, and was found to have sinus bradycardia on electrocardiogram (ECG) with a heart rate of 40-44 beats per minute.

Question: What is the reason for his sinus bradycardia?

He was then sent to HTJ by ambulance and arrived 4 hours after onset of chest pain. At the yellow zone Emergency Department, repeated ECG showed persistent sinus bradycardia with heart rate 40-50 beats per minute. He was given Tablet Aspirin (crushed) 300mg stat, IV Metoclopramide 10mg and IV Tramadol 50mg and his chest pain resolved soon after. Troponin I levels were normal (0.08).

Question: What diagnosis will you give for the chest pain at this point?

Bedside echocardiogram showed dilatation of all four heart chambers with no obvious hypokinetic areas or pericardial effusion.

Question: How will you explain the "dilatation of all four heart chambers with no obvious hypokinetic areas"?

He was later transferred to the Red Zone in view of persistent bradycardia for cardiac monitoring (38-40 beats/min) and given IV Atropine 0.5mg.

Question: Why did the doctors give atropine?

He was later transferred to the ward and started on Subcutaneous Fondaparinux 2.5mg OD, T. Aspirin 100mg OD and T. Simvastatin 20mg ON. Troponin I levels 6 hours later were normal as well (<0.04).

Question: What was he being treated as?

In ward, his pulse rate normalized and had no further complaints of chest pain. He was discharged well on Day 3 of admission with an appointment for an outpatient echocardiogram and discharge medications of T. Aspirin 100mg OD, T. Simvastatin 20mg ON and Sublingual Glyceryltrinitrate 1/1 when needed.

Question: What is the reason for the "appointment for an outpatient echocardiogram"? What other explanation can you offer for his chest pain? What investigation may be helpful in finding an answer to his clinical problem?

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