Presenting Complaint Mr T was admitted to hospital 3 days ago by ambulance (17 April 2012) due to chief complaint of 2 days

progressively chest pain. History of Presenting Complaint Mr T had 2 days history of chest pain, it started gradually and progressively getting worse until he admitted to hospital. He described the pain as sharp pain, the pain was retrosternal, compressive with radiation to left shoulders and was brought on by minimal exertion. He stated that the pain was 7 out of 10 scale. The pain was constantly present, he tried sublingual glyceryl trinitrates to relieve his pain but did not work. The pain became more significant with walking, talking and lying down. So, he sat up on his chair to relieve his pain. The chest pain was associated with dyspnoea. He was breathless on exertion and also at rest. He had orthopnoea and he used 3 pillows to sleep in night for the previous 4 years. He also had episodes of three times a week of paroxysmal nocturnal dyspnoea. He also had intermittent palpitations. They are irregular and an episode usually last for around 5 minutes. He denied any leg swellings. He also had 3 weeks history of productive cough, and the cough became more severe after each dialysis. He coughed out small amount of white sputum. He coughed out small amount of dark red blood streaks sometimes. On systemic reviews, he had postural hypotension. He always feels dizzy. He had three times of syncope in the previous 3 years. He denied any weakness of his body and limbs. He had headache occasionally and always been relieved by pain killer. He claimed that he is compliant with his medications. Past Medical History The patient was diagnosed with end stage renal failure 6 years ago. He has 3 times of kidney dialysis every week. He is diabetic for around 10 years. He has hypercholesterolaemia. He was just diagnosed with hypertension recently. He had aneamia due to chronic renal failure, and had few times history of blood transfusions. He had been admitted to hospital around 20 times in the previous 4 years due to kidney and heart diseases. He had history of stable and unstable angina. He did not have any surgery before. Medications and Allergies He is currently on aspirin 150mg, calcium carbonate tablets, Iron Fumarate, Vitamin B12, Folate and Vitamin C, Simvastatin, Perindopril, Amlodipine, Isosorbide Dinitrate, Trimetazidine, Metoprolol, s/c Enoxaparin, Clopidogrel, Nifedipine and Prazosine. He does not have any food and drug allergy. Social History He is currently staying in nursery home. He was a restaurant supervisor but resigned his job 3 years ago. He started dialysis 6 years ago and finished all his EPF savings. He is now financially supported by NGO. He just stopped smoking 3 weeks

ago, and he had been smoked regularly for 40 years, with pack years of 80. He drinks beer occasionally. Family History He married twice with a total of 5 children. He did not have good relationship with all the children and they never visit him. Her father passed away at the age of 70 due to Alzheimers complications and her mother at the age of 42 due to sudden cardiac death. He has 5 siblings, his youngest brother passed away at the age of 40 due to neurological disorder. Physical Examination On general inspection, the patient is sitting on the couch comfortably without respiratory distress. The patient was then placed 45 degree. He had a brachiocephalic fistula on his left elbow for haemodialysis. His radial pulse is weak, with normal rhythm and rate of 86bpm. He had nicotine stains on his right hand. There was no flapping tremor. He had conjunctiva pallor and slight jaundice. He did not central and peripheral cyanosis. His JVP was normal. Liver was not enlarged. There was no peripheral oedema. His apex beat was located at fifth intercostals space, but displaced 2.5 cm lateral to mid-clavicular line. No thrills and heave. Upon auscultation, first and second heart sound were heard with no added sound. During respiratory examinations, there was reduced chest expansion anteriorly and posteriorly. Tracheal was central. Tactile fremitus was symmetrical in both lungs. Percussion notes were resonant symmetrically in both lungs. There were bibasal crepitations in posterior lower zone of lungs. Breath sounds were reduced in both lungs, especially the posterior upper zone of lungs. No other added sounds heard. No other significant findings from other examinations. Differential Diagnosis 1. Pulmonary oedema secondary to acute coronary syndrome. The patient had history of acute coronary syndrome of unstable angina and acute myocardial infarction. His dyspnoea is caused by fluid congestion in lungs. 2. Pulmonary oedema secondary to congestive heart failure. His conditions with orthopnoea and PND suggestive of congestive heart failure. Physical examination revealed enlarged left ventricle with displacement of apex beat. 3. Acute coronary syndrome secondary to severe anaemia. His anaemia is caused by chronic renal failure. His complaint of tiredness, palpitations, dyspnoea, dizziness, angina and headache, which are symptoms of severe anaemia.