Summary 10

Mr. TKS a 58 year old malay man with newly diagnosed type 2 diabetes mellitus presented to the emergency department with central chest pain for 1 day which was crushing in nature, non-radiating, associated with profuse sweating, palpitations and nausea. The intensity of the pain did not change with breathing or position. On examination, vital signs were normal and JVP was not raised.

Question: What will you suspect when a patient with crushing chest pain has no tachycardia?

Cardiovascular examination showed a non-displaced apex beat with normal heart sounds heard. There was no murmurs and added heart sounds. Respiratory examination showed normal breath sounds with no crepitations heard. ECG was done and reveled ST elevation in leads AVL, V1-V5 and ST depression in II, III, AVF. Chest radiograph was normal. FBS was 8.5mmol/L.
He was diagnosed with acute anterolateral myocardial infarct with newly diagnosed type 2 diabetes mellitus. He was given crushed T. aspirin 300mg and T. clopidogrel 300mg and started on IV infusion streptokinase 1500000iu in 100ml normal saline for 1 hour. 1 hour post streptokinase ECG showed resolved ST elevation, T wave inversion in leads V1-V6, I, AVL and Q wave in V1-V3. In the ward, he was started on S/C Fondaparinux 2.5mg OD, T. Aspirin 150mg OD, T. Clopidogrel 75mg OD, T. Atorvastatin 40mg ON, T. Trimetazidine 20mg TDS and T. Bisoprolol 1.25mg OD.

Question: What is the reason for giving Fondaparinux after thrombolytic treatment? What is the purpose of giving Bisoprolol?

He was also given S/C actrapid 6 units in the ward. Echocardiogram was done and it reveled poor left ventricle function with ejection fraction of 30-35% with regional wall motion abnormalities of anterolateral wall, anterior wall and apical medial hypokinesia.

Question: What is the reason for the poor LV function? Is it likely to be permanent?

Chamber size was normal and there was no clots or thrombus seen.

Question: What is the implication of the normal chamber size?

He was discharged on the 4th day with T. Clopidogrel 75mg OD x 1/12, T. Aspirin 150mg OD x 3/12, T. Atorvastatin 40mg ON x 3/12, T. Trimetazidine 20mg TDS x 3/12, T. Bisoprolol 1.25mg OD x 3/12, T. Metformin 1g BD x 3/12, T. Perindopril 2mg OD x 3/12, S/L Glyceryl trinitrate 1 tablet PRN, TCA MOPD 2/52 to review RP, TCA MOPD 3/12 to review FBS, FBL, HbA1c, RP, LFT, referred to smoking cessation clinic and referral to cardiology department in HSAJB.

Question: Why is Perindopril added at the time of discharge?

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