Sadang, Saep, Salazar, Saludo, Salvador

Ward Case
GENERAL DATA
 General Data

N.A.O., 38, male, married, security

guard, Roman Catholic, residing in
Sampaloc

• Date admitted: November 3, 2007

• Date and time of interview: November 15, 2007; 11:00 am
• Informant: Patient
• Reliability: 85%
CHIEF COMPLAINT:

Dizziness
HISTORY OF PRESENT
ILLNESS
several episodes of dizziness

• 1st: at work, night shift

• not relieved by rest
• ECG: normal
• 2nd: USTH
• Dx: Vertigo
• 3rd (week after): middle of the
night
• RLE numbness
• USTH
• Dx: Transient Ischemic Attack
• Atorvastatin calcium (Lipitor),
Multivitamins with Iron (Iberet),
and ASA.
•easy fatigability
•slow down frequently while
cycling
• dizzy spell at a school function
• fell asleep
• woke up with nausea
•started vomiting
• 10 episodes of vomiting
• localized epigastric pain
• no relief from ASA
• relieved by food
• cold sweats, pale
 several episodes of dizziness
•Dx: Transient Ischemic Attack

easy fatigability

dizzy spells and vomiting

Admissi
REVIEW OF SYSTEMS
 Review of Systems
(-) decrease in appetite ,
General (-) weight loss

(-) itchiness,
Skin (-)photosensitivity

(-) blurring of vision, hearing difficulty,,discharge, stufiness,

HEENT
sore throat, epistaxis

(-) palpitations, chest pain,

CVS (-) nocturnal dyspnea, edema

Respiratory (-) cough, sputum, wheezing ,hemoptysis

(-) hematemesis, melena, hematochezia

Abdomen (-) abdominal pain, diarrhea, constipation
 Endocrine (-) polydypsia, polyphagia, heat/cold intolerance

Genital/Breast (-) abnormal discharge, sores

Peripheral
(–) phlebitis, varicosities, claudication
Vascular

Musculo-
(-) muscle wasting, abnormal posturing
skeletal

Neurologic (-) seizures, numbness, paralysis, tremors

Hematologic (-) no easy bruising, bleeding gums

Psychiatric (-) depression, suicidal thoughts, anxiety

PERSONAL MEDICAL
HISTORY
• Past Illnesses:
- Childhood Diseases: Measles
– Pulmonary Tuberculosis (1995)
• completed 6 month drug therapy

• Immunizations:
– Measles, Rabies, Tetanus

• Current/Maintenance Medications:
– Atorvastatin calcium (Lipitor), Multivitamins with
iron (Iberet), and ASA
 PERSONAL & SOCIAL HISTORY

• Diet
– Mixed diet consisting mainly of meat, vegetables, and
rice; fond of chicharon
• Smoking
– 8 pack years; stopped in 1995
• Alcohol
– Occasionally, not more than 1 bottle
• Substance use/abuse
– None
 FAMILY HISTORY
• (+)Hypertension – mother
• (+)“Heart attack” – Grandmother
• (-) Diabetes Mellitus, asthma, allergies,
arthritis, PTB, peptic ulcer, and cardiac
disease.
 PHYSICAL
EXAMINATION
 Physical Examination
System Admission
Conscious, coherent, oriented
as to time, person, and place.
Not in cardiorespiratory arrest
and was ambulatory
General BP 120/80; PR 28 bpm,
irregularly irregular;
RR 15 cycles per min; T 36°C
BMI 23.3, normal
•No bruising, icterus, cyanosis,
rashes, petechiae, or tattoos.
• Jaundice was not present.
Skin •Skin was warm and moist with
no active dematoses.
•Diaphoresis
Interview
Stenic, conscious, coherent,
oriented as to time, person,
and place.
Not in cardiorespiratory arrest
and was ambulatory
BP 110/80; PR 68 bpm;
RR 12 cycles per min; T 37°C
BMI 23.3, normal
• No bruising, icterus, cyanosis,
rashes, petechiae, or tattoos.
•Jaundice was not present.
•Skin was warm and moist with
no active dematoses.
 Physical Examination

System Admission Interview

• No evidence of trauma, deformities, or • No evidence of trauma, deformities, or

lumps on the patient’s head Pink
palpebral conjuctiva and anicteric
sclerae.
• EOM, direct & consensual pupillary
reflex intact
HEENT • Moist mucal bucosa, no oral lesions or
gum bleeding
• Ears did not have deformities, lumps,
and abnormal discharges
• Septum was in the midline
• Nasal turbinates were pink, no
epistaxis present in the throat.
lumps on the patient’s head Pink
palpebral conjuctiva and anicteric
sclerae.
• EOM, direct & consensual pupillary
reflex intact
• Moist mucal bucosa, no oral lesions or
gum bleeding
• Ears did not have deformities, lumps,
and abnormal discharges
• Septum was in the midline
• Nasal turbinates were pink, no
epistaxis present in the throat.

• Horizontally sutured incision measuring

•JVP was 7 cm 30° 6 cm was present at the anterior left
•Adynamic precordium, no heaves, • Adynamic precordium, no heaves,

CVS thrills, and lifts

• PMI at 5th LICS MCL
• Soft S1 and S2
thrills, and lifts
• PMI at 5th LICS MCL
• S1>S2 at the apex and S2>S1 at the
• Pulse (++) base, no murmurs
• Pulse (+)
 Physical Examination

System Admission Interview

• (-) supraclavicular retractions, • (-) supraclavicular retractions,

Respi- •
•
lungs resonant,
symmetrical chest expansion
•
•
lungs resonant,
symmetrical chest expansion,
ratory •
•
equal breath sounds
(-) crackles
•
•
equal breath sounds,
(-) crackles

• Flabby abdomen, • Flabby abdomen,

Abdo- •
•
Non tender,
(-) masses,
•
•
Non tender,
(-) masses,
men •
•
Liver edge smooth,
8 cm right MCL
•
•
Liver edge smooth,
8 cm right MCL

Genito- Unremarkable Unremarkable

Urinary
 Physical Examination
System Admission
• Conscious, coherent, oriented
to person, place and time.
• No cranial nerve
abnormalities
• (-) Nuchal rigidity, Kernig’s
CNS sign, and Brudzinski
• MMT was 5/5 on all
extremities
• Reflexes were normal and
coordination was good
There were no signs of
Musculo- inflammation at the joints
and full range of motion was
skeletal elicited.
Interview
•Conscious, coherent, oriented to
person, place and time.
• No cranial nerve abnormalities
• (-) Nuchal rigidity, Kernig’s sign,
and Brudzinski
• MMT was 5/5 on all extremities
• Reflexes were normal and
coordination was good
There were no signs of
inflammation at the joints and
full range of motion was elicited.
SUBJECTIVE OBJECTIVE
• 38 y.o., Male
• Dizziness • Stenic, conscious, coherent, oriented
• Nausea and vomiting as to time, person, and place.

• Cold sweats • Not in cardiorespiratory distress and

• RLE weakness (Dx Transient
Ischemic Heart Attack)
• Easy fatigability
• High fat diet
• (+) Family hx of HPN, MI
• Smoker
• (-) Chest pain, Palpitations,
Dyspnea
ambulatory.
• BP 120/80; PR 28 bpm, irregularly
irregular; RR 15; cycles per min; T 36°C
• Ht: 163 cm; Wt: 62 kg;
• BMI 23.3, normal
•JVP 7 cm at 30 degrees
•Weak pulses
 Assessment
• Etiology: Atherosclerosis
• Anatomy: Coronary arteries, Myocardium, SA
Node
• Physiology: Ischemia, Conduction Disorder
• Functional: Class III
• Objective: C
 Plan (Diagnostic)
• History taking and PE
• Lab work-up:
– CBC, Renal fxn test (BUN, Crea), Lipid profile, Liver fxn
test, Serum electrolyte, Thyroid fxn
– Chest X-ray
– 12-lead ECG
• Other ancillary procedures:
– 2-D echo
– Exercise testing
– Holter monitoring
– Coronary Angiogram
 Plan (Therapeutic)
• Stabilize and monitor the patient
• Placement of pacemaker
• Anticoagulant therapy
• Follow-up consultation with cardiologist to
– document patient’s status
– prevent complication and disease progression
• Minimize activity
– Titrate their level of exertion to minimize
symptoms
Indications for Permanent Pacemaker Implantation in Sick Sinus Syndrome

Class I*
1. SSS with documented symptomatic bradycardia, including frequent sinus pauses that
produce symptoms. In some patients, bradycardia is iatrogenic and will occur as a
consequence of essential long-term drug therapy of a type and dosage for which there are
no acceptable alternatives.
2. Symptomatic chronotropic incompetence
Class IIa
1. SSS occurring spontaneously or as a result of necessary drug therapy, with heart rate less
than 40 bpm when a clear association between significant symptoms consistent with
bradycardia and the actual presence of bradycardia has not been documented.

Class IIb
1. In minimally symptomatic patients, chronic heart rate less than 30 bpm while awake

Class III
1. SSS in asymptomatic patients, including those in whom substantial sinus bradycardia
(heart rate less than 40 bpm) is a consequence of long-term drug treatment
2. SSS in patients with symptoms suggestive of bradycardia that are clearly documented as
not associated with a slow heart rate
3. SSS with symptomatic bradycardia caused by nonessential drug therapy