1. Approach to Patient with
Chest Pain
MPRPC Group 1
Section C

2. General Data Name: E.R. Age/Sex: 53/F Status: Married
Address: 608 Lacson Ave, Sampaloc, Manila
Race: Filipino
Religion: Roman Catholic
Occupation: Housewife
Date of Admission: Nov. 17, 2009

3. HISTORY OF PRESENT ILLNESS
2 years PTA
Incidentally diagnosed as hypertensive (150/90)
Given nifedipine (Calcibloc) not compliant, taken as needed
Experienced headache
Sought consult at Ospital ng Maynila
3 months PTA

4. HISTORY OF PRESENT ILLNESS
Experienced first episode of chest pain and heaviness characterized by sharp pain at sternal area, non-radiating and lasting for 10 minutes. (precipitating factor; grade?)
Weakness (type?) of both upper extremities but relieved by herbal oil massage
Jose Reyes Memorial Hosp.
BP 160/90
2 months PTA
Experienced body ache (type?) precipitated by stress
1 day PTA

5. HISTORY OF PRESENT ILLNESS
A few minutes after waking up, experienced gradual chest tightness and heaviness (describe)
USTH ER
Chief complain: chest pain
BP 200/110
IV nicardipine
Oxygen
Sublingual nitroglycerin
ECG & chest X-ray
5 hours PTA
Admission

6. Past Medical History (+) cataract, OD (2008) (+) cataract, OS (2004)
(-) previous hospitalizations
(-) DM, heart disease, PTB, asthma, cancer, allergies
Unrecalled immunizations

7. Family History Father – HPN, colon cancer, Mother - DM
died 63 y/o due to CVA
Mother - DM
died 62 y/o due to CVA
All siblings – HPN, DM
(-) TB, asthma, allergies

8. Personal and Social History
Preference to sweet and salty foods
(-) smoking history
(+) exposure to second hand smoke (34 years)
(-) alcohol consumption
Denies illicit drug use

9. Review of Systems
General: no significant weight loss; no anorexia; no headache
Skin: no itchiness
HEENT: blurring of vision L>R; no tinnitus; no aural discharge
Thorax: no breast pain
Pulmonary: no respiratory distress; no dyspnea; no PND; no orthopnea

10. Review of Systems GIT: no abdominal pain; no diarrhea & vomitting
GUT: no difficulty in urination
Endocrine: no polydipsia, polyphagia, polyuria; no heat and cold intolerance
MS: No joint pain; no muscle pains; no weakness
Neurological: No dizziness

11. Physical Examination On admission (Nov. 17, 2009)
Upon PE (Nov. 18, 2009)
General Survey
Conscious, coherent, stretcher-borne, in cardiorespiratory distress
Vital Signs
BP: 200/100, supine LUE; 190/100, RUE, SBP 190, LLE, SBP 190 RLE;
PR: 88, regular;
HR:88, regular;
RR:24;
T 36.5
Conscious coherent, ambulatory, not in cardiorespiratory distress
BP: 110/70;
PR: 76, regular;
HR: 76, regular;
RR: 20, regular;
T 36.0
Anthropometric Measurements:
Height: 157cm Weight: 74kg BMI: 30

12. Physical Examination On admission Upon PE Skin HEENT
Warm, moist skin, no flushing, no active dermatoses
HEENT
Pink palpebral conjunctivae, anicteric sclera, (+) ROR, hazy cornea
No nasoaural discharge, septum midline, moist buccal mucosa
No tragal tenderness AU, non-hyperemic external auditory canal AU, intact tympanic membrane AU
Warm, moist skin, no flushing, no active dermatoses
Pink palpebral conjunctivae, anicteric sclerae, (+) ROR
no nasal or aural discharge, no nasal deformities, midline septum
Intact tympanic membrane, no tragal tenderness

13. Physical Examination On admission Upon PE HEENT
Moist buccal mucosa, tongue midline, non-hyperemic PPW, tonsil not enlarged
no limitation in motion, Trachea midline, thyroid gland not enlarged, neck veins not distended, no cervical lymphadenopathy, (-) carotid bruits
Moist buccal mucosa, no oral ulcers
supple neck, thyroid gland not enlarged, no palpable cervical lymphadenopathy, trachea midline, neck veins not distended

14. Physical Examination On admission Upon PE Cardiovascular
Adynamic precordium, JVP 3cm at 30 degree, AB at 5th LICS 11cm from the midsternal line, tapung, 2cm in diameter, no heaves, no thrills, no lifts S1>S2 apex, S2>S1 base, no murmurs
Pulses full and equal, no edema, no cyanosis, no clubbing
Adynamic precordium, apex beat at 5th LICS 11cm from the midsternal line, no heaves trills lifts, apex S1>S2, base S2>S1, no murmurs, JVP 4cm at 30 degrees
No edema, pulses full and equal on all extremities

15. Cardiac Auscultogram CAP rapid upstroke gradual down stroke
JVP 3 cm at 30° A P T M S1 S2 S1 S2 S1 S2 S1 S2
Precordial Activity:
Adynamic precordium
No heaves, lifts, or thrills
Apex beat:
5th LICS
11 cm from midsternal line

16. Physical Examination On admission Upon PE Pulmonary
Symmetrical chest expansion, no retractions, no lagging, equal tactile and vocal fremiti, resonant on percussion, clear breath sounds
No chest retractions, no use of accessory muscles, normal breathing pattern, symmetrical chest expansion, unimpaired transmission of voice and tactile fremiti, resonant on both sides, vesicular breath sounds on both sides

17. Physical Examination On admission Upon PE Gastrointestinal
Flabby abdomen, no striaes, no visible peristalsis, NABS, (-) bruits, tympanitic on percussion, no tenderness, liver edge not palpable, Traube’s space not obliterated
Flabby abdomen, normoactive bowel sounds, tympanitic, non-tender, liver dullness 10 cm, Traube’s space not obliterated

18. Physical Examination On admission Upon PE Neurologic
Awake, alert, conscious, oriented to 3 spheres
CN: no anosmia, pupils 2-3mm ERTL, EOMs intact, V1V2V3 intact and equal, can clench teeth, can smile, can frown, intact hearing, (+) gag reflex, can raise both shoulders against resistance, uvula midline on phonation, can shrug shoulders, tongue midline on protrusion
Conscious, awake, oriented to person, place and time, can follow commands
Cranial nerves intact, pupils equally responsive to light, extraocular muscles intact, no facial asymmetry, can smile, frown, clench teeth, puff cheeks, normal gross hearing, uvula midline, (+) gag reflex, able to shrug shoulders, turn face against resistance

19. Physical Examination On admission Upon PE Neurologic
Motor: 5/5 on the lower extremities, 5/5 on the upper extremities, no fasciculations, atrophy
No babinski, bilateral
No sensory deficit
No nuchal rigidity, Kernig’s, Brudzinski’s
Motor 5/5 over all extremities, good tone, no atrophy, no fasciculation
No sensory deficits
(-) Babinski , Kernig, Brudzinski
No nuchal rigidity

20. Salient Features Pertinent Positive Age: 53 Sex: F
BP on admission: 200/100, known hypertensive since ____
RR 24 bpm (tachypnea)
BMI = 30 (obese)
(+) family history
Lifestyle
Hazy cornea (?)

21. Salient Features Pertinent Negative (make bullets brief!)
Neck veins not distended
No heaves, no thrills, no lifts, S1>S2 apex, S2>S1 base, no murmurs
Apex beat at 5th LICS 11cm from the midsternal line
Pulses full and equal, no edema, no cyanosis, no clubbing
No pertinent respiratory findings
No epigastric pain

22. Chest Pain
Cardiovascular
Pulmonary
Gastrointestinal
Musculoskeletal

23. DIAGNOSIS: Hypertension
Definition:
The elevation of blood pressure above normal range expected of a particular age group
- The Bantam Medical Dictionary

24. Blood Pressure Classification
Systolic, mmHg
Diastolic, mmHg
Normal
<120
<80
Prehypertension
80-89
Stage 1 hypertension
90-99
Stage 2 hypertension
≥160
≥100
Isolated systolic hypertension
≥140
<90
On Admission
LUE 200/110
RUE 190/100
LLE 190 systolic
RLE 190 systolic
Upon PE
110/70
Harrison’s Internal Medicine, 17th Ed

25. Primary hypertension vs. Secondary hypertension
Familial
Environmental + genetic
Secondary
Due to another medical condition

26. Target Organ Damage Heart disease Stroke or TIA Nephropathy
Peripheral arterial disease
Retinopathy

27. Risk Factors for Hypertension (summarized)
Old age (M>45; F>55)
Obesity
Gender – female
Lifestyle – diet, drinking alcohol, smoking, amount of exercise
Positive family history
Chronic stress
Prehypertension – blood pressure in 120–139/80–89 mmHg range

28. Pathology

29. Hypertensive Emergency VS. Hypertensive Urgency
Hypertensive Emergency - severe BP elevation (> 180/120 mm Hg)
- progressive target-organ dysfunction
Hypertensive Urgency - severe BP elevation
- NO target-organ dysfunction
Rate of change of BP is directly related to the likelihood that an acute hypertensive syndrome will develop

30. Critical level or
rapid rate of rise and increased
vascular resistance
Endothelial damage
Spontaneous natriuresis
Inc, Endothelial permeability
Intravascular volume
depletion
Decrease in vasodilators,
nitric oxide, prostacyclin
Platelet and fibrin
deposition
Increase in vasoconstrictors
(renin–angiotensin,
catecholamines
Fibrinoid necrosis and
intimal proliferation
Further increase in
blood pressure

31. Severe blood
pressure elevation
Tissue ischemia
End-organ dysfunction

32. Pathologic Consequences of Hypertension
Heart- most common cause of death in hypertensive patients
- left ventricular hypertrophy diastolic dysfunction, CHF
- Inc. risk of CHD, stroke, arrhythmias
Brain – brain infarction and hemorrhage (intracerebral or subarachnoid)
- encephalopathy- vasodilation and hyperperfusion
- related to autoregulation failure
Signs and symptoms:
severe headache
nausea
vomiting

33. Kidney- direct damage to glomerular capillaries due to hyperperfusion
- may progress to glomerulosclerosis
- renal tubules will eventually become ischemic and atrophic
Blood Vessels – atherosclerosis secondary to long-standing elevated pressure
Eye - retinal hemorrhages, exudates

34. Ischemia
Blood supply – important for oxygenation and elimination of waste products
Ischemia refers to a lack of oxygen due to inadequate perfusion of the myocardium
Imbalance between oxygen demand and supply

35. Factors affecting oxygen supply and demand:

36. Atherosclerosis
The most common cause of myocardial ischemia is obstructive atherosclerotic disease of the coronary arteries

37. Macrophage and T lymphocytes Redeposition of oxidized LDL Inflammation
Damage to artery wall
Macrophage and T lymphocytes
Redeposition of oxidized LDL
Inflammation
Migration and enlargement of muscle cells
Narrowing of lumen

38. Major risk factors for atherosclerosis
Cigarette smoking
Hypertension (BP>/= 140/90mmHg) DM
Family history of premature CHD
Age (men >/= 45 years, women>/=55 years)
Lifestyle: obesity(BMI>/= 30kg/m2, physical inactivity, atherogenic diet)

39. Concentric Hypertrophy

40. Ancillary Procedures

41. Blood Tests Results Normal values FBS 100 mg/dL 70.9-110 Cholesterol
Triglycrides
106 mg/dL
0-210
HDL
46.2 mg/dL
30-90
LDL
145 mg/dL
66-178
SGPT
34.2 U/L
0-31
Creatinine
0.80 mg/dL
Sodium
141 mmol/L
Potassium
3.5 mmol/L
3.8-5

42. CBC
Hgb
113 g/L
RBC
3.62 x 10^12/L
Hct
0.34
MCV
92.70 U^3
87 +-5
MCH
31.20 pg
29 +-2
MCHC
33.70 g/dL
34 +-2
RDW
11.90
MPV
8.30 fL
Platelet
298 x 10^9/L
WBC
5.70 x 10^9/L
Differential Count
Neutrophils
0.49
Lymphocytes
0.47
Monocytes
0.03
Eosinophils
0.01
Basophils

43. Urinalysis Color – Light yellow Transparency – Slightly Turbid pH 6.5
Specific Gravity 1.015
Albumin and Sugar – Negative
Pus cells 2-4/ hpf
Squamous cells +
Renal Cell – few
Bacteria – few
Amorphous urate +
Calcium oxalate ++

45. Radiology

47. PHARMACOLOGY

48. Identify Problems
Chest pain
Hypertension
Diet

49. Set therapeutic goals To gradually decrease systolic blood pressure
To prevent recurrence of chest pain
To prevent progression of symptoms
To promote and develop a healthy lifestyle

50. Pharmacologic Therapies
Dihydropyridine calcium channel blocker – nicardipine
Angiotensin receptor blocker – irbesartan
Diuretic – hydrochlorothiazide
β blocker – metoprolol
Nitrate – isosorbide mononitrite
Antihyperlipidemic - simvastatin
Aspirin

51. Non-pharmacologic Approaches
Lifestyle change/modifications
Lose extra weight
Diet: less salt
Exercise
Follow DASH (Dietary Approach to Stop Hypertension) which includes diet rich in fruits, vegetables, and low-fat dairy products and is low in fat.