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Ferdinand B. Sta. Ana, Jr.2012-24716

HISTORY  Identifying Data• Name: Nilda Caragay

• Age: 71

• Status: Married• Occupation: Mananahi (Retired), Household work

• Residence: Pandacan, Manila

• Province: Laguna

Chief Com!aint" #Mabigat at kumikirot ang dibdib” 

$i%tory of &re%ent I!!ne%%"• Onset: Sudden

• Progression: intermittent

• Quality: Constricting, heavy

• Radiation: Epigastric, neck, back, arms

• Severity: 10/10

• Duration: Hours

• Associated symptoms: dyspnea

May 12, 2014

• Fatigued due to outing

• Abrupt heaviness in epigastric area which radiated upward, chest,

neck, and back

• Severity: 10/10

• Was brought to PGH ICU

• Was given 3 sublingual nitrates (isodryl)

o Pain alleviated in other aread while there was residual pain in

chest area

• Was diagnosed withSick Sinus Syndrome

• Was also medicated with Losartan, Captopril and Clopidogrel

• Labs: cTnI, 2D Echo, Ultrasound, CXR

o CXR impressions: cardiomegaly, pulmonary congestivechanges, atherosclerotic aorta

May 26, 2014

• Surgically operated to put pacemaker; discharged 2 days after

1st Week of June 2015

• N.C. was admitted to PGH for angina and stayed for 5 days

• There was abrupt heaviness in epigastric area which radiated upwardand to the chest, neck and back

• Severity: 10/10

• Was given 3 sublingual nitrates (isodryl)

o Pain alleviated in other aread while there was residual pain in

chest area

• Labs: cTnI, 2D Echo, Ultrasound, CXR

o CXR impressions: cardiomegaly, pulmonary congestive

changes, atherosclerotic aortaSeptember 27, 2015

• N.C. was admitted to PGH for angina

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• There was abrupt heaviness in epigastric area which radiated upward

and to the chest, neck and back

• Severity: 10/10

• Was given 3 sublingual nitrates (isodryl)

o Pain alleviated in other aread while there was residual pain in

chest area

• Currently waiting for angiogram and angioplasty• Medications:

Medicine Dosage

Enalapril 5 mg, 2x a day

ASA (aspirin) 80 mg, once a dayAtorvastatin 8 mg, once a day

Isosorbide mononitrate 30 mg, once a day

Metformin 500 mg, 2x a day

Clopidogrel 75 mg, once a day

Carvedilol 12.5 mg, 2x a day

MX3 50 mg, once a day

Omeprazole 40 mg, once a day

&a%t 'edi(a! $i%tory• Surgical: had previous cholecystectomy

• Obstetric

o G11P10(10, 0, 1, 10)

o Pre-eclampsia in last pregnancy (29 yrs old)

• Medical

o Hypertension since last pregnancy

o Hyperglycemia: glucose levels reaching 250

Fami!y $i%tory• Hypertension from both maternal and paternal sides

• Brother died from MI at 32 yrs old; Parents also died from MI

• No diabetes

• No cancer

• No TB

&er%ona! and So(ia! $i%tory• Has 10 living children

• Smoked for 2 months some years ago

• Son also smokes but does it outside the house

• Drinks alcoholic beverages occasionally

• Mahilig kumain ng matataba (e.g. chicharon)

• Laging nilalagyan ng Maggie Magic Sarap ang pagkain

)e*ie+ of Sy%tem%General (-) polyuria

(-) nocturia(-) tea-colored urine(-) dysuria(-) difficulty/pain in urinating

HEENT (+) edema

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(-) joint pain or swelling(-) clubbing

Respiratory (+) dyspnea(-) cough(-) colds

Cardiovascular (+) angina

(+) PND(+) orthopnea(-) palpitations

GIT (+) abdominal pain (epigastric)(-) vomiting(-) diarrhea(-) constipation(-) flatulence(-) melena(-) hematochezia(-) hematemesis

Urinary (-) polyuria(-) nocturia(-) tea-colored urine(-) dysuria(-) difficulty/pain in urinating

Extremities (+) edema(-) joint pain or swelling(-) clubbing

Skin (-) jaundice(-) pallor(-) cyanosis(-) petechiae(-) ecchymoses

PHYSICAL

EXAM

ita! Sign%• Temperature: was not able to measure• Pulse Rate: 60 bpm

• Respiratory Rate: 22 breaths / min

• Blood Pressure: 116/62

e( /amination•  JVP = 2 cm H2O at 300

o CVP = 7 cm H2O at 300

• Full and equal carotid pulses

• (-) carotid bruits

In%e(tion• No Precordial Bulge

• PMI at 5th ICS LMCL

&a!ation• Apex beat at 5th ICS LMCL

• No heaves, thrills or lifts

&er(%%ion

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• Cardiac Area of Dullness noted 8 cm from the Midsternal Line to 5th 

ICS LMCL

A%(!tation• Normal Rate

• Regular Rhythm

• No S3, No S4, No Murmurs

/tremitie%• Pulse Rate for all pulse sites (Brachial, Radial, Femoral, Popliteal,

Posterior Tibial, Dorsalis Pedis) are64 bpm withnormal amplitude.Similar in volume and rhythm bilaterally.

• No cyanosis, clubbing and bipedal edema observed

DIFFERENTIAL

DIAGNOSIS

PRIMARY

WORKING

IMPRESSION

Aorti( di%%e(tionA(te myo(ardia! infar(tion/%ohagea! re3

Non-ST-segment Elevation – Acute Coronary Syndrome

LABORATORY/

WORK-UP

12-lead ECGSerial measurement of cTnI separated by a certain number of hours dependingon sensitivity of assay used

PATHOPHYSIOLO

GY 

Four processes:1) Rupture of unstable atheromatous plaque

• Leads to formation of typically nonocclusive superimposed

thrombus with subsequent impaired myocardial perfusion2) Coronary arterial vasoconstriction3)Imbalance between the supply and demand of the myocardium foroxygen

4)Gradual intraluminal narrowing of an epicardial coronary arteryReference: Mann, Zipes, Libby, Bonow and Braunwald. (2014).Braunwald’sheart disease: A textbook of cardiovascular medicine(10th ed). Philadelphia, PA:Saunders.

MANAGEMENT • Diuretic

• Beta blockers

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