SUBMITTED TO:

SUBMITTED BY:

SILLIMAN UNIVERSITY MEDICAL SCHOOL

DATE:
de los Santos, Rosheil Mae C.

REPRESENTATIVE CASE
IDENTIFYING DATA: A case of G.C., 53 years old, male, single, engineer, from Dumaguete City
CHIEF COMPLAINT: Chest discomfort
HISTORY OF PRESENT ILLNESS:
The condition was noted about a year PTA, as onset of on and off chest pain, described as transient pricking of few
seconds to a minute duration, and occasionally as vague discomfort at the midchest for about 3-5 minutes. This was
usually noted after exertion and relieved with rest. There was occasional epigastric discomfort relieved with
burping. However, there were no diaphoresis, palpitation and shortness if breath. No consultation was done.
6 hours PTA, while at the gym lifting weights, he experienced chest pain/heaviness lasting less than 10 minutes
associated with weakness of the left arm, cold sweats and palpitation. This was relieved after resting.
1 hour PTA, he was awakened due to retrosternal pain, described as squeezing , about 29 minutes, with 7-8/10 pain
scale, with radiation to the back, associated with diaphoresis, palpitation, burning epigastric pain, nausea and
shortness of breath thus was brought to the emergency room (ER).
PAST MEDICAL HISTORY:
He is hypertensive for 5 years on Losartan 59ng daily. He is diabetic for 2 years on regular intake of Metformin
500mg twice daily. He had previous elevations in cholesterol and was on Atorvastatin for only a month.
PERSONAL-SOCIAL HISTORY:
He was a smoker of 29 pack years, stopped for 1 year. An occasional alcoholic beverage drinker. He has. No regular
exercise.
FAMILY HISTORY:
Both parents have hypertension, the father is diabetic. There is no history of sudden death.
REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
General Survey:
General Survey: General Survey: He was admitted conscious, coherent, anxious,
HEENT:
ambulatory, afebrile, not in respiratory distress
Chest and Lungs:
Vital Signs: BP = 100/60mmHg
HR = 104/min
RR = 20/min
Temp.
Cardiovascular:
= 36.50C
Gastrointestinal:
O2 Sat = 97%
Weight = 68kg
Height = 5'7"
Musculoskeletal:
Skin: Warm, sweaty, good turgor
Genitourinary:
HEENT: Anicteric sclera, pink palpebral conjuctivae, (-) TPC, (-) NVE, (-) Bruit
CNS:
C/L: Equal chest expansion, slight tenderness on the left costochondral area, clear
breath sounds
(NO DATA GIVEN)
Cardiovascular: Adynamic precordium, apex beat at the left 5th ICS, MCL,
distinct S1 and S2, regular rhythm, tachycardic, (-) murmur
Abdomen: Flabby, NABS, soft, no organomegaly
Extremities: No edema, full pulses
Neuromascular: Within normal
II. PRIMARY IMPRESSION
DIAGNOSIS
RULE IN
RULE OUT
ACUTE
ID: 53 years old, male
CANNOT BE RULED OUT
CORONARY
CC: Chest discomfort
SYNDROME:
HPI:
STEMI
1yr PTA: On and off chest pain, described as transient pricking
of few seconds to a minute duration
6hrs PTA: Discomfort at the midchest for about 3-5 minutes
Chest pain/heaviness lasting less than 10 minutes associated

with weakness of the left arm, cold sweats and palpitation

1 hour PTA: Retrosternal pain with radiation to the back
associated with diaphoresis, palpitation, burning epigastric pain,
nausea and shortness of breath
PMH: Hypertension, Diabetes, and Hypercholesterolemia
PSH: Smoker of 29 pack years, occasional alcoholic beverage
drinker, and no regular exercise
FH: Hypertension, Diabetes
PE: Tachycardic
Labs:
Increased Troponin I and CK-MB
Increased FBS = 136 mg/dl HBA1C = 7
Increased Total cholesterol, Triglycerides, HDL-C, LDL-C
ECG = ST Elevation
III. DIFFERENTIAL DIAGNOSIS
DIAGNOSES
RULE IN
ACUTE
ID: 53 years old, male
CORONARY
CC: Chest discomfort
SYNDROME:
HPI:
NSTEMI
1yr PTA: On and off chest pain, described as transient pricking
of few seconds to a minute duration
ACUTE
6hrs PTA: Discomfort at the midchest for about 3-5 minutes
CORONARY
Chest pain/heaviness lasting less than 10 minutes associated
SYNDROME:
with weakness of the left arm, cold sweats and palpitation
UNSTABLE
1 hour PTA: Retrosternal pain with radiation to the back
ANGINA
associated with diaphoresis, palpitation, burning epigastric pain,
nausea and shortness of breath
PMH: Hypertension, Diabetes, and Hypercholesterolemia
PSH: Smoker of 29 pack years, occasional alcoholic beverage
drinker, and no regular exercise
FH: Hypertension, Diabetes
PE: Tachycardic
Labs:
Increased Troponin I and CK-MB
Increased FBS = 136 mg/dl HBA1C = 7
Increased Total cholesterol, Triglycerides, HDL-C, LDL-C
CHRONIC STABLE ID: 53 years old, male
ANGINA
CC: Chest discomfort
PECTORIS
HPI:
1yr PTA: On and off chest pain usually noted after exertion
6hrs PTA: Discomfort at the midchest for about 3-5 minutes
1 hour PTA: Pain with radiation to the back
PMH: Hypertension, Diabetes, and Hypercholesterolemia
PSH: Smoker of 29 pack years, occasional alcoholic beverage
drinker, and no regular exercise
FH: Hypertension, Diabetes
Labs:
Increased Troponin I and CK-MB
Increased FBS = 136 mg/dl HBA1C = 7
Increased Total cholesterol, Triglycerides, HDL-C, LDL-C
ACUTE
ID: 53 years old, male
PERICARDITIS
CC: Chest discomfort
HPI:
6 hours PTA: While at the gym lifting weights, he experienced
chest pain
1 hour PTA: He was awakened due to retrosternal pain
PMH: Hypercholesterolemia
PE: Tachycardic
Labs:
Increased Troponin I
Increased Total cholesterol, Triglycerides, HDL-C, LDL-C

RULE OUT
(+) Labs: ST - Elevation

(+) Labs: ST - Elevation

Chronic Stable Angina

Pectoris is unrelieved by
rest.

(-)
(-)
(-)
(-)

Fever
Cough
Dysphagia
Friction Rub

AORTIC
DISSECTION

ECG = ST Elevation
ID: 53 years old, male
CC: Chest discomfort
HPI:
6hrs PTA: Chest pain associated with weakness of the left arm
PMH: Hypertension
Labs:
Increased Troponin I and CK-MB
ECG = ST Elevation

IV. RATIONAL LABORATORY & DIAGNOSTIC TESTS

NORMA
PATIENTS
TEST
L
INTERPRETATION
RESULT
VALUES

(-) Syncope/altered
mental status
(-) Bibasilar crackles
(-) Increased in VP
(-) Muffled heart sounds
(-) Diastolic Murmur
(-) Asymmetrical Pulse
(-) Bruit
(-) Labs: Mediastinal
Widening on Chest- Xray
AVAILABILIT
Y

FURTHER LABORATORY WORKS TO ORDER TO SUPPORT THE DIAGNOSIS

LABORATORY TEST
INTERPRETATION/NECESSITY

SCAN
V. FINAL DIAGNOSIS

VI. PATHOPHYSIOLOGY

COST

VII. THERAPEUTIC MANAGEMENT

LIST OF PROBLEMS
1. Acute Coronary Syndrome:
STEMI
2. Dyslipidemia
3. Hypertension
4. Diabetes Mellitus

1. To
2. To
3. To
4. To
5. To
6. To
7. To
ADVICE AND INFORMATION

PHARMACOLOGIC MANAGEMENT
DRUG NAME
EFFICACY

P-DRUGS
DRUG NAME

EFFICACY

VIII. MONITORING AND FOLLOW-UP

THERAPEUTIC OBJECTIVES
identify and treat underlying cause of the disease
return the vital sign parameters (HR) to normal
relieve pain
control Cholesterol level within normal limits
control the Fasting Blood Sugar level within normal limits
restore/improve body strength
prevent complications
NON-PHARMACOLOGIC
MANAGEMENT

SAFETY

SAFETY

SUITABILITY

SUITABILITY

COST

Cardiac rehabilitation (cardiac rehab) is a professionally supervised program to help people recover from heart
attacks, heart surgery and percutaneous coronary intervention (PCI) procedures such as stenting and angioplasty.
Cardiac rehab programs usually provide education and counseling services to help heart patients increase physical
fitness, reduce cardiac symptoms, improve health and reduce the risk of future heart problems, including heart
attack.
Cardiac Rehabilitation Program includes:

Medical Evaluation. The medical staff uses this information to figure out patients needs and limitations
and to tailor a rehabilitation program and help you set goals.

Physical Activity Program. Training often starts in a group setting where your heart rate and blood
pressure are monitored during physical activity. The patient works with a physical therapist, exercise
physiologist or other healthcare professional. Through this program, the patients will learn how to check
their heart rate and level (intensity) of activity.

Counseling and Education. Counseling and education will help patients to understand their condition and
how to manage it such as planning a healthy diet, how to withdraw from smoking and how to cope with
stress.

Support and Training. Support and training to help patient return to work or normal activities and to help
them learn to manage their heart condition.
XI. PRESCRIPTION WRITING

X. REFERENCES