APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C

1. APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C

2. GENERAL INFORMATION Name: B.C. Age: 60 years old Gender: Male Citizenship: Filipino Religion: Roman Catholic Occupation: Farmer Address: Bulacan Source: Patient CHIEF COMPLAINT: CHEST PAIN

3. Chest pain - grade 3/10 - substernal - heaviness - effort related (3km walk) - relieved after 4 minutes of rest - recurs once a month Chest pain - grade 6/10 - 10- 20 meters walk - radiation to the left arm 2 years 1 month Consult and admission

4. PAIN ASSESSMENT AND ALGORITHM P - precipitating, aggravating, relief Q - quality R - radiation, location S - severity (1-10) T - timing

5. PAST MEDICAL HISTORY • (+) Hypertension for 10 years • Highest BP 200/100 • Usual BP 140-150/90 • On irregular intake of metoprolol 50mg • No previous surgical illness requiring hospitalization

6. FAMILY HISTORY • Father: (+) HPN, (+) DM, sudden death at 55y/o • Mother: (+) HPN, stroke at 60y/o • Brother: (+) HPN, (+) DM • Sister: (+) HPN, (+) DM

7. PERSONAL AND SOCIAL HISTORY • Patient is a rice farmer in Bulacan • Fond of eating tuyo, bagoong, alamang • 50-pack year smoking history • Drinks 1-2 bottles of gin 3x a week • No illicit drug use

8. REVIEW OF SYSTEMS • General Survey • No significant weight loss • No loss of consciousness and headache • HEENT • No blurring of vision • No ear discharge or tinnitus • Respiratory • No cough • No colds • No dyspnea

9. REVIEW OF SYSTEMS • Gastro-intestinal • No epigastric pain • No diarrhea • No constipation • No melena • No hematochezia • Genitourinary • No dysuria • No frequency • No urgency • No pollakiuria

10. REVIEW OF SYSTEMS • Musculo-skeletal • No joint pains • Endocrine/Metabolism • No polyuria • No polydypsia • No polyphagia • No heat or cold intolerance

11. General Survey Conscious Coherent Normosthenic Not in Cardiopulmonary distress Vital Signs BP 160/90 PR 100/min regular RR 19/min T 37oc PHYSICAL EXAMINATION

12. PHYSICAL EXAMINATION • Anthropometric Measurements • Height: 1.5 m • Weight: 52.6 kg • BMI: 23 • HEENT • Pink palpebral conjunctiva • Anicteric sclera • No nasal nor aural discharge • Moist buccal mucosa • No neck mass

13. Respiratory Symmetrical chest expansion No retraction Resonant, unimpaired transmission of vocal and tactile fremiti Clear breath sounds Gastrointestinal Abdomen flabby Normoactive bowel sounds Tympanitic, nontender Liver dullness 10cm Traube’s space not obliterated Extremities Pulses ++ on all extremities No pedal edema PHYSICAL EXAMINATION

14. Adynamic precordium, apex beat 6th LICS AAL, (-) heaves JVP 4.5cm at 45 deg CAP PV AV TV S1 S2 S1 S2 MV

15. CHIEF COMPLAINT: Chest Pain “An unpleasant sensation in the anterior wall of the thorax associated with actual or potential tissue damage and mediated by specific nerve fiber to the brain where conscious appreciation may be modified by various factors. “ Stedmans Medical Dictionary, 27th edition

17. ORGAN SYSTEMS THAT COULD BE INVOLVED Reference: Mosby’s Guide to Physical Examination, 6th edition

18. ORGAN SYSTEMS THAT COULD BE INVOLVED Reference: Mosby’s Guide to Physical Examination, 6th edition

20. SALIENT FEATURES (SUBJECTIVE) Pertinent Positive (+) • 60 y/o male • Farmer • Chest pain • Hypertension • Preference for salty foods • 50 pack year smoking history • Alcohol drinker Family History • Hypertension • Diabetes mellitus • stroke Pertinent Negative (-) • Fatigue • Dyspnea • Palpitations • Weight loss • Cough • Epigastric pain • Joint pain • Polyuria, polydypsia, polyphagia • Heat and cold intolerance

21. SALIENT FEATURES Objective • BP 160/90 • Apex beat 6th LICS AAL

22. PATHOPHYSIOLOGY

24. MYOCARDIAL ISCHEMIA • occurs when myocardial oxygen demand exceeds oxygen supply

25. PATHOGENESIS OF ATHEROSCLEROSIS

26. Endocrine (DM) Hyperlipidemia Genetic Functional Impairment of Endothelium Increased LDL or other lipid influx Initiation of Inflammation Monocyte Influx Inadequate Wound Healing Smooth muscle cell proliferation Matrix Deposition Atheroma Formation Thrombus Formation Occlusion of artery MECHANISM OF OCCLUSION

28. Development of atherosclerotic plaque

29. MAJOR RISK FACTORS Age: male > 45 y/o female > 55 y/o Family history in a first degree relative of premature CAD (acute MI) male relative < 55 y/o female relative < 65 y/o Diabetes mellitus Chronic smoking Hypertension Obesity Dyslipidemia MINOR RISK FACTORS Sedentary lifestyle Chronic infection/ inflammation hyperhomocysteinemia Reference: ATP III

30. PATHOLOGY

31. GROSS SPECIMEN OF THE HEART Showing yellowish atherosclerotic plaques Image retrieved from: http://library.med.utah.edu/WebPath/CVHTML/CV005.html

32. HYPERTROPHIED HEART Image retrieved: http://www.studentconsult.com/common/cfm

34. NORMAL CORONARY ARTERY Image retrieved from: http://library.med.utah.edu/WebPath/CVHTML/CV005.html

35. narrowing of the lumen due to build up of atherosclerotic plaque Abn. >75% narrowing, assoc. w/ angina CORONARY ARTERY WITH ATHEROSCLEROSIS Image retrieved from: http://library.med.utah.edu/WebPath/CVHTML/CV005.html

36. Normal myocardium Cardiac muscle w/ ischemia • central nuclei • syncytial arrangement of the fibers • pale pink intercalated disks • myocytes hypertrophied • large, dark nuclei Image retrieved: http://www.studentconsult.com/common/cfm and http://library.med.utah.edu/WebPath/TUTORIAL/MYOCARD/MI031.html

37. PLAQUE STABILIZATION Stable plaque Unstable plaque Thinner vs thickerfibrous cap More vs fewerinflammatory cells • Lipid core • Greater lipid content and loose necrotic tissue create less echo on an ultrasound (hypoechogenicity), while dense fibrous tissue in more stable plaque creates more echo (hyperechogenicity) Toschi V et al. Circulation. 1997;95:594-599; Libby P. Circulation. 1995;91:2844-2850; Schartl M et al. Circulation. 2001;104:387-392.

38. LV hypertrohy Increase myocardial oxygen demand Hypoxia Ischemia Necrosis Increase anaerobic respicration Increase Lactic Acid CHEST PAIN

39. REFERRED PAIN

41. Stimulus  PGE2, H+ ions, bradykinin, K+ ischemia • Primary viscerosensory fibers terminate in Lamina I & V • Spinal segments also receive cutaneous somatosensory input from dermatomes of the chest wall and arm • Tract cells in the posterior horn that receive somatosensory input may also be activated • Response  Cerebral cortex interprets the pain as originating from the surface of the body

42. RADIOLOGIC AND ANCILLARY TESTS

43. DIAGNOSTIC TESTS Reference: Harrison’s Principles of Internal Medicine 17th Edition Chest X ray ECG Ancillary test - Lipid profile - fasting blood sugar

44. X-RAY Reference: Harrison’s Principles of Internal Medicine 17th Edition Important in the diagnosis of the following: cardiac enlargement ventricular aneurysm signs of heart failure Important in assessing the degree of cardiac damage

45. X-RAY

46. NORMAL ECG ACTIVATION

47. S-T SEGMENT ELEVATION

48. S-T SEGMENT DEPRESSION

49. T-WAVE INVERSION

50. ANCILLARY TESTS Reference: Harrison’s Principles of Internal Medicine 17th Edition • Lipid Profile • TC: < 200 mg/dL • LDL: < 130 mg/dL • HDL: > 60 mg/dL • Fasting Blood Sugar • 70-99 mg/dL