78 year old retired police officer from Muar with a history of Ischaemic Heart Disease for 5 years, was admitted to Hospital Pakar Sultanah Fatimah with the chief complaint of progressive breathlessness for one month

On examination
He is in a propped up position with a nasal prong in place attached to the oxygen. There is use of accessory muscles of respiration. There is no pallor, icterus or pedal oedema. Pulse is irregularly irregular and apex beat is located in the 6th intercostal space, 2 cm lateral to the midclavicular line. There are bibasal course crepitations on auscultation of the chest.
He had a raised ESR and a prothrombin time of 14.2 seconds, increased serum creatinine of 120, uric acid 456. his pH was 7.473, pCO2 28.0, and pO2 of 74.5
Morphologic diagnosis: Congestive cardiac failure with atrial fibrillation.
Etiological diagnosis : Ischaemic Heart Disease

Exploring personal and social background.
Patient used to tap rubber during his childhood and during his free time he used to play soccer with his friends. He started smoking cigarettes at about the age of 15 and used to smoke about a pack a day till the age of 65 after which he stopped completely due to the advice from the Doctor. He used to meet many of his friends before having breathlessness but cannot now because of the condition.  The hospital is situated 18 miles from where he lives and he travels by motorcycle. He lives with his wife but his children do not stay with him.


Benjamin Lim-8th Semester