Approach to Patient with Chest Pain MPRPC Group 1 Section C

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 (?)

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

Chest Pain Cardiovascular Pulmonary Gastrointestinal Musculoskeletal

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

Blood Pressure Classification Systolic, mmHg Diastolic, mmHg Normal <120 <80 Prehypertension 120-139 80-89 Stage 1 hypertension 140-159 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

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

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

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

Pathology

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

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

Severe blood pressure elevation Tissue ischemia End-organ dysfunction

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

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

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

Factors affecting oxygen supply and demand:

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

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

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)

Concentric Hypertrophy

Ancillary Procedures

Blood Tests Results Normal values FBS 100 mg/dL 70.9-110 Cholesterol 131-239 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 0.5-1.2 Sodium 141 mmol/L 137-147 Potassium 3.5 mmol/L 3.8-5

CBC Hgb 113 g/L 120-170 RBC 3.62 x 10^12/L 4.0-6.0 Hct 0.34 0.37-0.54 MCV 92.70 U^3 87 +-5 MCH 31.20 pg 29 +-2 MCHC 33.70 g/dL 34 +-2 RDW 11.90 11.6-14.6 MPV 8.30 fL 7.4-10.4 Platelet 298 x 10^9/L 150-450 WBC 5.70 x 10^9/L 4.5-10.0 Differential Count Neutrophils 0.49 0.50-0.70 Lymphocytes 0.47 0.20-0.40 Monocytes 0.03 0.00-0.07 Eosinophils 0.01 0.00-0.05 Basophils 0.00-0.01

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 ++

Radiology

PHARMACOLOGY

Identify Problems Chest pain Hypertension Diet

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

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

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.