Summary 4

Madam ZBD, a 81 years old Malay lady with underlying ischemic heart disease diagnosed last year with ischemic heart disease after an acute episode of myocardial infarction and with hypertension presented with worsening of dyspnoea for the past one week. It is associated with chest tightness and palpitations on physical exertion. She also complains of productive cough with scanty white sputum for past three days. She has orthopnea, paroxysmal nocturnal dyspnoea and oedema over both feet. She had no chest pain since last year and had frequently defaulted follow ups since diagnosis and she was prescribed after discharge last year with medications T. Aspirin 100mg od, T. Plavix 75mg od, T.Perindopril 4mg bd, T. Simvastatin 40mg on and Sublingual glyceryl trinitrate prn.

Question: Why do you think she was prescribed Perindopril? What medication do you think should also have been prescribed last year?

On physical examination, her pulse rate was 108 beats per minute, blood pressure was 179/100 mmHg, respiratory rate was 24 breaths per minute with oxygen saturation of 99% on face mask oxygen 5L. She had physical signs of pedal oedema, elevated jugular venous pressure 4cm above sternal angle and on chest examination, the apex beat was deviated and felt over the sixth intercostal space 2cm lateral to midclavicular line and heart sound S3 was heard with bibasal fine lung crepitations. Electrocardiogram showed left bundle branch block and Q waves in lead V3,V4 with poor R waves progression.

Question: What do you think the Q waves in the ECG represent? What is the cause of her LBBB?

Cardiac marker Troponin I was 0.18mg/ml, not raised. Chest radiograph showed cardiomegaly and increased pulmonary vasculatures marking. Echocardiogram found her ejection fraction was less than 40 percent and she had dilated left atrium and ventricle.

Question: Why is her left atrium dilated?

Laboratory investigations revealed she has normocyctic hypochromic anaemia and creatinine level was slightly raised at 200 mmol/L.

Question: What is wrong with the value of serum creatinine as written above?

She was treated with diuretics,IV Frusemide 40mg bd and sublingual nitroglycerin. Her dsypnoea and leg oedema had improved throughout the stay and on the fourth day of admission, she had minimal basal lung crepitations and reduced pedal oedema and was discharged with T. Frusemide 20mg od, T.Perindorpil 4mg, T. Simvastatin 40mg on, Sublingual glyceryl trinitrate prn and T. Ferrous Fumarate 200mg od. She was counselled on fluid restriction intake and compliance to medications with follow ups.

Question: Is there anything different you would do with regards to her discharge prescription?

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