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

3

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

4

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

5

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

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

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

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

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

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.