COMMUNITY MEDICINE CASE 1

NAME: RAZEEN RIYASAT ALI

ID:20180014

GENERAL DATA
Name: Javed Ali
Age: 36-year-old
Gender: Male
Marital status: Married
Address: Saweni, Lautoka
Informant: The Patient

Chief Complain:
36 Y/O FID male with nil comorbidities referred from private GP with
complains of:
Left sided chest Pain for 1 week

History of Presenting illness:

Patient was having left chest pain for 1 week which radiated to the left upper
limb and left shoulder tip. The patient said that initially he was able to do his
daily activities without much difficulty but for the past 24-48 hours his
condition has become worse. Patient describes the pain as sharp stabbing pain.
He says that he sometimes has difficulty breathing and has on and off Shortness
of Breath. The pain score was 9/10 and is exacerbated with movement.

The patient was seen twice at Natabua health center and was given omeprazole
IVI and pylokit. ECG was done twice both of which came back normal.

Review of Systems:

Constitutional Symptoms:
(-) Fever
(-) Headache
(-) Chills and Rigors
(-) Fatigue or night sweats
(-) Weight loss

Cardiovascular:
(+) Left chest pain
(-) Palpitations
(+) SOB with exertion
(-) Swelling in legs
Respiratory
(-) Wheezing
(+) on and off cough
(-) productive cough
(-) coughing up blood

Gastrointestinal:
(+) Burping
(-) abdominal pain
(-) constipation
(-) LBM, Diarrhea
Normal Bowel Output

Genitourinary:
(+) PU
(-) Dysuria
(-) pyuria
(-) Scrotal swelling
(-) Itching
(-) inconsistency
(-) Urgency

Past Medical History:

- Had a surgery done on right hand due to a tendon injury 5 years ago.
- No known comorbidities

Medication History:
- Pylokit
- Nil Allergies

Family History:
- Maternal side are K/C/O IHD

Social History:
- Was a smoker for 20 years consuming 20 sticks per day. Left 1 ½ year
ago.
- Works as a Carpenter
- Does not consume Alcohol or kava.
General Appearance:
- Patient is conscious, coherent, converses in full sentences however gives
a delay in response. Is in distress and is holding his left chest. Is oriented
to T/P/P and GCS 15/15.

Vitals:
- BP: 106/73
- PR: 69 beats/min
- SO2: 99% (RA)
- T: 36.4
- RR: 22 beats/ min

HEENT:
(-) headache,
(-) dizziness,
(-) photophobia,
(-) alopecia,
(-) eye discharge,
(-) icteric sclerae,
(-) conjunctival pallor,
(-) ear discharge,
(-) nasal discharge,
(-) sore throat,
(-) tonsilitis,
(-) lymphadenopathy,
(-) tracheal tug,
(-) elevated JVP,
(-) central cyanosis,
(-) neck stiffness,
(+) dry oral mucosa
(+) Pupils equal and reactive to light,

Chest:
Inspection: chest wall is symmetric, (-) scars, (-) chest wall indrawing.
Palpation: trachea midline, normal chest expansion, normal tactile vocal fremitus.
Percussion: (-) dullness on percussion.
Auscultation: clear lung fields, good air entry, (-) wheezes, (-) crackles, (-) harsh
breath sounds, (-) Velcro crackles, (-) pleural rub.
Abdomen

• Inspection: (-) scars, (-) abdominal distention

• Auscultation: normal bowel sound
• Palpation: soft, non-tender, (-) organomegaly, (-) guarding, (-) rebound
tenderness
• Percussion: tympanic

Extremities:
- Good volume pulses
- CR <2 seconds
- (-) Edema

Investigations:
a) FBC:
- WBC: 9700 /ml (Normal)
- Hgb: 15.3 (Normal)
- MCV/ PCV: 84/45 (Normal)
- Platelets: 233k/ ul (Normal)

Interpretation: Normal, No active illness

b) Troponin:
- 0.51 ng/mL (0.0.1)

Interpretation: - 0.1-0.39 troponin level is seen in 99th percentile of healthy population. If

troponin is =0.4 then there is a probable Myocardial infarction. In this patient the troponin is
>0.51 hence highly likely of Myocardial infarction.
c) ECG:

Interpretation: T wave inversion in leads II and aVF

Assessment:
1) ACS: NSTEMI vs Unstable Angina
2) R/O Gastritis.

Plans:
1) Admit to mans ward
2) FBC/ UECr/ Lipids/ Troponin 1 done
3) Cardiac Loading done:
Aspirin 300mg PO OD
GTN 600 mg SL PRN
Clopidogrel 300mg PO PD
Pantoprazole 40mg IV

4) Simvastatin 80mg PO nocte

5) Patient informed to buy clexane 60U SC BD x 3/7.
6) MMT 10ml PO PRN for any presiding gastritis due to use of statins
7) Repeat ECG after 1 hour
8) Strict bed rest
9) Monitor and refer PRN
10) Dietitian to see