chest pain approach to patient with mprpc group 1 section c
TRANSCRIPT
Chest Pain
Approach to Patient with
MPRPC Group 1Section 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
•Incidentally diagnosed as hypertensive (150/90)•Given nifedipine (Calcibloc) not compliant, taken as needed
3 months PTA
2 years PTA
•Experienced headache•Sought consult at Ospital ng Maynila
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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
1 day PTA
2 months PTA
•Experienced body ache (type?) precipitated by stress
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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
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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, – 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
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Physical ExaminationOn admission (Nov. 17, 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
Upon PE (Nov. 18, 2009)
– 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
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Physical ExaminationOn admission• Skin
– 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
Upon PE
– 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
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Physical Examination
On admission• 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
Upon PE
– Moist buccal mucosa, no oral ulcers
– supple neck, thyroid gland not enlarged, no palpable cervical lymphadenopathy, trachea midline, neck veins not distended
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Physical Examination
On admission• 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
Upon PE
– 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
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Cardiac Auscultogram
P
T
A
M
S1 S1 S1S2 S2S2S2S1
Precordial Activity:
Adynamic precordium
No heaves, lifts, or thrills
Apex beat:
5th LICS
11 cm from midsternal line
JVP 3 cm at 30° CAP rapid upstroke gradual down stroke
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Physical Examination
On admission• Pulmonary
– Symmetrical chest expansion, no retractions, no lagging, equal tactile and vocal fremiti, resonant on percussion, clear breath sounds
Upon PE
– 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
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Physical Examination
On admission• Gastrointestinal
– Flabby abdomen, no striaes, no visible peristalsis, NABS, (-) bruits, tympanitic on percussion, no tenderness, liver edge not palpable, Traube’s space not obliterated
Upon PE
– Flabby abdomen, normoactive bowel sounds, tympanitic, non-tender, liver dullness 10 cm, Traube’s space not obliterated
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Physical Examination
On admission• 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
Upon PE
– 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
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Physical Examination
On admission• 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
Upon PE
– Motor 5/5 over all extremities, good tone, no atrophy, no fasciculation
– No sensory deficits– (-) Babinski , Kernig,
Brudzinski– No nuchal rigidity
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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 (?)
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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
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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
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Blood Pressure Classification
On Admission• LUE 200/110• RUE 190/100• LLE 190 systolic• RLE 190 systolic
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
Harrison’s Internal Medicine, 17th Ed
Upon PE• 110/70
Primary hypertension vs.
Secondary hypertension
Primary• 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 levelorrapid rate of rise and increasedvascular resistance
Endothelial damage Spontaneous natriuresis
Intravascular volumedepletion
Fibrinoid necrosis andintimal proliferation
Platelet and fibrindeposition
Inc, Endothelial permeability
Decrease in vasodilators,nitric oxide, prostacyclin
Further increase inblood pressure
Increase in vasoconstrictors(renin–angiotensin,catecholamines
Severe bloodpressure 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
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 207 mg/dL 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 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.