SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO:

DATE:

SUBMITTED BY:

de los Santos, Rosheil Mae C.

I. REPRESENTATIVE CASE

IDENTIFYING DATA: A case of G.C., 53 years old, male, single, engineer, from Dumaguete City

CHIEF COMPLAINT: Chest discomfort

HISTORY OF PRESENT ILLNESS:

The condition was noted about a year PTA, as onset of on and off chest pain, described as transient pricking of few seconds to a minute duration, and occasionally as vague discomfort at the midchest for about 3-5 minutes. This was usually noted after exertion and relieved with rest. There was occasional epigastric discomfort relieved with burping. However, there were no diaphoresis, palpitation and shortness if breath. No consultation was done.

6 hours PTA, while at the gym lifting weights, he experienced chest pain/heaviness lasting less than 10 minutes associated with weakness of the left arm, cold sweats and palpitation. This was relieved after resting.

1 hour PTA, he was awakened due to retrosternal pain, described as squeezing , about 29 minutes, with 7-8/10 pain scale, with radiation to the back, associated with diaphoresis, palpitation, burning epigastric pain, nausea and shortness of breath thus was brought to the emergency room (ER).

PAST MEDICAL HISTORY:

He is hypertensive for 5 years on Losartan 59ng daily. He is diabetic for 2 years on regular intake of Metformin 500mg twice daily. He had previous elevations in cholesterol and was on Atorvastatin for only a month.

PERSONAL-SOCIAL HISTORY:

He was a smoker of 29 pack years, stopped for 1 year. An occasional alcoholic beverage drinker. He has. No regular exercise.

FAMILY HISTORY:

Both parents have hypertension, the father is diabetic. There is no history of sudden death.

REVIEW OF SYSTEMS

PHYSICAL EXAMINATION

General Survey:

HEENT:

Chest and Lungs:

Cardiovascular:

Gastrointestinal:

Musculoskeletal:

Genitourinary:

CNS:

(NO DATA GIVEN)

General Survey: General Survey: He was admitted conscious, coherent, anxious, ambulatory, afebrile, not in respiratory distress

Vital Signs: BP = 100/60mmHg HR = 104/min RR = 20/min Temp. = 36.50C

O2 Sat = 97% Weight = 68kg Height = 5'7"

Skin: Warm, sweaty, good turgor

HEENT: Anicteric sclera, pink palpebral conjuctivae, (-) TPC, (-) NVE, (-) Bruit

C/L: Equal chest expansion, slight tenderness on the left costochondral area, clear breath sounds

Cardiovascular: Adynamic precordium, apex beat at the left 5th ICS, MCL, distinct S1 and S2, regular rhythm, tachycardic, (-) murmur

Abdomen: Flabby, NABS, soft, no organomegaly

Extremities: No edema, full pulses

Neuromascular: Within normal

II. PRIMARY IMPRESSION

DIAGNOSIS

RULE IN

RULE OUT

ACUTE CORONARY SYNDROME: STEMI

ID: 53 years old, male

CC: Chest discomfort

HPI:

1yr PTA: On and off chest pain, described as transient pricking of few seconds to a minute duration

6hrs PTA: Discomfort at the midchest for about 3-5 minutes

Chest pain/heaviness lasting less than 10 minutes associated with weakness of the left arm, cold sweats and palpitation

1 hour PTA: Retrosternal pain with radiation to the back associated with diaphoresis, palpitation, burning epigastric pain, nausea and shortness of breath

PMH: Hypertension, Diabetes, and Hypercholesterolemia

PSH: Smoker of 29 pack years, occasional alcoholic beverage drinker, and no regular exercise

FH: Hypertension, Diabetes

PE: Tachycardic

Labs:

Increased Troponin I and CK-MB

Increased FBS = 136 mg/dl HBA1C = 7

Increased Total cholesterol, Triglycerides, HDL-C, LDL-C

ECG = ST Elevation

CANNOT BE RULED OUT

III. DIFFERENTIAL DIAGNOSIS

DIAGNOSES

RULE IN

RULE OUT

ACUTE CORONARY SYNDROME: NSTEMI

ID: 53 years old, male

CC: Chest discomfort

HPI:

1yr PTA: On and off chest pain, described as transient pricking of few seconds to a minute duration

6hrs PTA: Discomfort at the midchest for about 3-5 minutes

Chest pain/heaviness lasting less than 10 minutes associated with weakness of the left arm, cold sweats and palpitation

1 hour PTA: Retrosternal pain with radiation to the back associated with diaphoresis, palpitation, burning epigastric pain, nausea and shortness of breath

PMH: Hypertension, Diabetes, and Hypercholesterolemia

PSH: Smoker of 29 pack years, occasional alcoholic beverage drinker, and no regular exercise

FH: Hypertension, Diabetes

PE: Tachycardic

Labs:

Increased Troponin I and CK-MB

Increased FBS = 136 mg/dl HBA1C = 7

Increased Total cholesterol, Triglycerides, HDL-C, LDL-C

(+) Labs: ST - Elevation

ACUTE CORONARY SYNDROME:

UNSTABLE ANGINA

(+) Labs: ST - Elevation

CHRONIC STABLE ANGINA PECTORIS

ID: 53 years old, male

CC: Chest discomfort

HPI:

1yr PTA: On and off chest pain usually noted after exertion

6hrs PTA: Discomfort at the midchest for about 3-5 minutes

1 hour PTA: Pain with radiation to the back

PMH: Hypertension, Diabetes, and Hypercholesterolemia

PSH: Smoker of 29 pack years, occasional alcoholic beverage drinker, and no regular exercise

FH: Hypertension, Diabetes

Labs:

Increased Troponin I and CK-MB

Increased FBS = 136 mg/dl HBA1C = 7

Increased Total cholesterol, Triglycerides, HDL-C, LDL-C

Chronic Stable Angina Pectoris is unrelieved by rest.

ACUTE PERICARDITIS

ID: 53 years old, male

CC: Chest discomfort

HPI:

6 hours PTA: While at the gym lifting weights, he experienced chest pain

1 hour PTA: He was awakened due to retrosternal pain

PMH: Hypercholesterolemia

PE: Tachycardic

Labs:

Increased Troponin I

Increased Total cholesterol, Triglycerides, HDL-C, LDL-C

ECG = ST Elevation

(-) Fever

(-) Cough

(-) Dysphagia

(-) Friction Rub

AORTIC DISSECTION

ID: 53 years old, male

CC: Chest discomfort

HPI:

6hrs PTA: Chest pain associated with weakness of the left arm

PMH: Hypertension

Labs:

Increased Troponin I and CK-MB

ECG = ST Elevation

(-) Syncope/altered mental status

(-) Bibasilar crackles

(-) Increased in VP

(-) Muffled heart sounds

(-) Diastolic Murmur

(-) Asymmetrical Pulse

(-) Bruit

(-) Labs: Mediastinal Widening on Chest- X-ray

IV. RATIONAL LABORATORY & DIAGNOSTIC TESTS

TEST

NORMAL VALUES

PATIENTS RESULT

INTERPRETATION

AVAILABILITY

COST

FURTHER LABORATORY WORKS TO ORDER TO SUPPORT THE DIAGNOSIS

LABORATORY TEST

INTERPRETATION/NECESSITY

SCAN

V. FINAL DIAGNOSIS

VI. PATHOPHYSIOLOGY

VII. THERAPEUTIC MANAGEMENT

LIST OF PROBLEMS

THERAPEUTIC OBJECTIVES

1. Acute Coronary Syndrome: STEMI

2. Dyslipidemia

3. Hypertension

4. Diabetes Mellitus

1. To identify and treat underlying cause of the disease

2. To return the vital sign parameters (HR) to normal

3. To relieve pain

4. To control Cholesterol level within normal limits

5. To control the Fasting Blood Sugar level within normal limits

6. To restore/improve body strength

7. To prevent complications

ADVICE AND INFORMATION

NON-PHARMACOLOGIC MANAGEMENT

PHARMACOLOGIC MANAGEMENT

DRUG NAME

EFFICACY

SAFETY

SUITABILITY

P-DRUGS

DRUG NAME

EFFICACY

SAFETY

SUITABILITY

COST

VIII. MONITORING AND FOLLOW-UP

Cardiac rehabilitation (cardiac rehab) is a professionally supervised program to help people recover fromheart attacks,heart surgeryand percutaneous coronary intervention (PCI) procedures such as stenting and angioplasty. Cardiac rehab programs usually provide education and counseling services to help heart patients increase physical fitness, reduce cardiac symptoms, improve health and reduce the risk of future heart problems, including heart attack.

Cardiac Rehabilitation Program includes:

Medical Evaluation. The medical staff uses this information to figure out patients needs and limitations and to tailor a rehabilitation program and help you set goals.

Physical Activity Program. Training often starts in a group setting where your heart rate and blood pressure are monitored during physical activity. The patient works with a physical therapist, exercise physiologist or other healthcare professional. Through this program, the patients will learn how to check their heart rate and level (intensity) of activity.

Counseling and Education. Counseling and education will help patients to understand their condition and how to manage it such as planning a healthy diet, how to withdraw from smoking and how to cope with stress.

Support and Training. Support and training to help patient return to work or normal activities and to help them learn to manage their heart condition.

XI. PRESCRIPTION WRITING

X. REFERENCES