HO, CHRISTINE EVAN B.

Internal Medicine November 6, 2019

PATIENT HISTORY

DATE AND TIME OF INTERVIEW: November 4, 2019; 9 AM INFORMANT: Patient

HISTORY TAKEN BY: Frias, Mallillin RELIABILITY: Good
HANDEDNESS: Right

GENERAL DATA
Mr. MB, 51 years old, male, Filipino, married, Roman Catholic and is currently residing in
Montalban, Rodriguez, Rizal consulted at Amang Rodriguez Memorial Medical Center on
November 4, 2019.

CHIEF COMPLAINT: Chest pain

HISTORY OF PRESENT ILLNESS

6 days prior to consultation, patient had sudden onset of chest pain of 9/10 grading, heavy
and squeezing localized at the retrosternal area, which lasted for approximately 30 minutes and
was associated with difficulty in breathing and increased heart rate. No radiation noted. Patient
sought consult at Montalban Infirmary Hospital. There was sudden loss of consciousness noted
on the way to the hospital that he remembered waking up in the hospital, was given oxygen and
was nebulized which provided relief of symptoms. Physician suggested admission but patient
refused.
5 days prior to consult there was no persistence of symptoms but patient was uneasy
worrying for another sudden chest pain which prompted consult at Amang Rodriguez Memorial
Medical Center and was admitted.

COURSE IN THE WARD

On the day of admission, October 30, 2019, patient experienced another episode of chest
pain on the same location but with increased severity of 10/10. Pain was associated with blurring
of vision, headache and difficulty in breathing which he described as a feeling of suffocation and
impending doom. He was notably given by medications which alleviated the symptoms.
In the interim, patient is now stable.

PAST MEDICAL HISTORY

 Patient had unrecalled immunizations
 2004 – Patient was diagnosed with hypertension, no medications taken.
 2009 – history of acute myocardial infarction (MI)
 2019 – Second episode of acute MI
 No history of diabetes mellitus, cancer, or thyroid problems.
 No known allergies to food and drugs.
 No history of blood transfusion, nor psychiatric illnesses.
 No history of surgery, nor hospitalizations.

FAMILY HISTORY
 Mother and father, unrecalled age, died of MI.
 Eldest brother, unrecalled age, also died of MI
 No history of heredofamilial diseases such as bronchial asthma, pulmonary tuberculosis,
kidney, liver, lung diseases and cancer.
PERSONAL & SOCIAL HISTORY
Patient is currently working as a private driver in Manila. Patient prefers to eat fatty and
salty food with 3-5 cups of rice. Patient exercises for 30 minutes at least 3 times in a week. Patient
drinks 3-4 bottles of beer, occassionaly for at least four times in a year. Patient smokes 2 packs
of cigarettes per day since he was 14 years of age with 74 pack-years. Denied illicit drug-use.

REVIEW OF SYSTEMS

SYSTEMS SYMPTOMS

Constitutional (-) anorexia; (-) loss of appetite

symptoms

Skin (-) rashes; (-) lumps; (-) pruritus; (-) changes in color; (-) erythema; (-) jaundice;
(-) cyanosis

Head (-) head injury; (-) vertigo

Eyes (-) pain; (-) redness; (-) itchiness; (-) photophobia; (-) double vision; (-) excessive
lacrimation; (-) periorbital swelling; (-) trauma history; (+) use of reading glasses

Ears (-) tenderness; (-) deafness; (-) tinnitus; (-) ear discharge

Nose and Sinuses (-) epistaxis; (-) discharge; (-) nasal obstruction; (-) sinus pain

Mouth and Throat (-) toothache; (-) bleeding gums;(-) sore throat; (-) hoarseness; (-) tonsillar pain

Neck (-) stiffness; (-) limitation of motion; (-) mass; (-) sensation of lump in throat

Respiratory (+) cough, non-productive dry cough, 1 year in duration, occur mostly at night; (-)
hemoptysis; (-) audible wheezing

Peripheral (-) intermittent claudication; (-) leg cramps; (-) varicose veins; (-) edema; (-)
tenderness

Gastrointestinal (-) dysphagia; (-) hematemesis; (-) constipation; (-) melena; (-) hematochezia; (-)
regurgitation

Genitourinary (-) dysuria; (-) hesitancy; (-) hematuria; (-) incontinence

Musculoskeletal (-) edema; (+) swelling of joints, ankles and metatarsal joint, drink mefenamic acid
to alleviate pain; (-) stiffness; (-) numbness; (-) limitation of movement

Neurologic (-) vertigo; (-) loss of consciousness; (+) focal numbness, of the left arm last
february 14, which occurred while driving; (-) paresthesia; (-) speech disorder; (-)
loss of memory; (-) confusion

Hematologic (-) abnormal bleeding; (-) pallor; (-) easy bruising

 PHYSICAL EXAMINATION

General Survey: Patient is conscious, coherent with normal speech. No signs of

cardiorespiratory distress.

VITAL SIGNS: BP: 150/80mmHg CR: 98bpm RR: 20cpm Temp: 36.6°C O2 Sat: 98%

EXAMINATION OF THE HEAD

The hair is black, clean scalp, no mass or tenderness. Cranium is normocephalic, symmetric, and
no lesions.

The face is symmetrical, brown-skinned. No masses, normal facie and no involuntary movements.

EXAMINATION OF THE EYES

Eyebrows are thin, evenly distributed, no swelling, no edema, no erythematous rim, no lesions on
the eyelids. There is normal palpebral fissures. Eyelashes are thin, evenly distributed, directed
outward with no matting. Sclera is anicteric. Presence of arcus senilis on both eyes. Pink palpebral
conjunctiva, normal set of eyeballs, pupils are 4mm constricting to 3mm in diameter, equally round
in shape, symmetrical and can perceive light and accommodation. Disc margins sharp,
hemorrhages noted on the right and left lower quadrant of the right eye, no exudates. Lens are
transparent and clear, no opacities. No nystagmus, (+) red-orange reflex.

Visual acuity using Jaeger’s chart, 20/100 OU

Snellen chart not done.
Extraocular muscles intact.

EXAMINATION OF THE EARS

Symmetrical auricles, no deformities no lesions, no tenderness, auditory canals are patent, no
discharge, no swelling or redness of the walls of the canal, tympanic membranes are pearly white
and intact, normal contour with visible cone of light, and has no perforation. Whispered acuity,
Weber and Rinne were not done.

EXAMINATION OF THE NOSE

Symmetrical, no deformities, bilaterally patent vestibules, pink mucosa without lesions, nasal
septum is in midline, no perforations, pink turbinates, flat, moist, with abundant hair and not
congested, no nasal discharges, no tenderness over the frontal and maxillary sinuses.

EXAMINATION OF THE ORAL CAVITY

Lips are moist and symmetrical, no deformities. Buccal mucosa is pink. Tongue is symmetrical,
moist and in midline upon protrusion and retraction, can move without difficulty. Uvula is at
midline.

EXAMINATION OF THE NECK

Normal in size, symmetrical, no visible mass, swelling or deformity, no tenderness, full range of
motion, no neck vein distention. Trachea is in the midline, with palpable cervical lymph nodes.
Thyroid gland is not palpable.

EXAMINATION OF THE THORAX AND LUNGS

Skin is brown, normal chest shape with no visible deformities, lateral diameter is larger than
anteroposterior diameter, no visible dilated blood vessels, no use of accessory muscles.
Symmetrical chest expansion, no retractions, no lagging. No tenderness. Equal tactile fremiti.
Resonant on all lung fields. No bilateral crackles, wheezes, rhonchi, or other adventitious sounds.
Predominantly vesicular breath sound. Bronchophony, egophony, pectoriloquy not done.
EXAMINATION OF THE CARDIOVASCULAR SYSTEM
Adynamic precordium, no precordial bulging, no visible pulsations, apex beat at 5th ICS left MCL,
regular rate, regular rhythm, no murmur, no thrills. S1 heard best at the apex while S2 was heard
best at the base. No S3 and S4 noted.

EXAMINATION OF THE PERIPHERAL VASCULAR SYSTEM

No clubbing of nails nor cyanosis both on the upper and lower extremities. No varicosities noted.
Brisk and equal pulses on the radial, posterior tibial and dorsalis pedis with grade 2 pulsations.
Diminished but equal pulses noted on the popliteal with grade 1 pulsations.

EXAMINATION OF THE ABDOMEN

Abdomen is globular, soft, symmetrical with brown skin. No striae nor ecchymoses noted.
Umbilicus is inverted, no visible pulsations in the epigastric region, no dilated superficial blood
vessels, bowel sounds are hypoactive at 4 per minute, no bruits heard over the epigastrium, right
and left paraumbilical areas, no friction rubs, no palpable masses, no organomegaly, no
tenderness. Tympanitic on all quadrants. Liver is smooth and sharp-edged.

EXAMINATION OF THE MUSCULOSKELETAL SYSTEM

No bony deformities, inflammation or tenderness noted. No muscle atrophy. Full range of motion
on the upper extremities. Normal grip strength. Monoarticular knee joint pain on the right, no
increase in warmth or redness. No swelling and stiffness. Decreased range of motion upon
flexion, extension, internal and external rotation noted. Bilateral ankle joint pain with palpable
swelling, increased warmth, diffuse tenderness and redness.

DIFFERENTIAL DIAGNOSIS

Primary Working Impression: Acute Myocardial Infarction

DIAGNOSIS RULE IN RULE OUT

Acute Chest pain CANNOT BE RULED ● 12-lead ECG

Myocardial Occurred at rest OUT ○ Stress test
Infarction Lasted for 30 ● Cardiac Biomarkers
minutes
(cTnT, cTnI, CK-MB)
Crescendo pattern
(+) Dyspnea

Unstable Occur at rest (or with Retrosternal location ● 12 - Lead ECG

Angina minimal exertion) heavy and squeezing ● Cardiac Biomarkers
>30minute-duration pain (cTnT, cTnI, CK-MB)
Crescendo pattern
 Stable (+)Chest pain (+) Persistent chest ● Lipid Profile Test
Angina ● Squeezing pain for 30 minutes - ● 12-lead ECG
● Retrosternal (Crescendo- ● Stress test
in location decrescendo in nature,
● Occurred at 2-5 mins)
rest
● Family
history of
heart disease
● Hypertensive

Heart Failure Dyspnea (-) paroxysmal ● Routine Lab

Weakness nocturnal dyspnea ○ CBC, serum
Occurred at rest (-) pulmonary crackles electrolytes,
Nocturnal cough BUN, serum
crea, hepatic
enzymes,
and urinalysis
● 12-lead ECG
● CXR

MANAGEMENT & THERAPEUTIC PLAN

Once the diagnosis of acute STEMI is made, early management of the patient involves
simultaneous achievement of several goals:
● Relief of ischemic pain
● Assessment of hemodynamic state and correction of abnormalities present
● Initiation of reperfusion therapy with primary percutaneous coronary intervention (PCI) or
fibrinolysis
● Antithrombotic therapy to prevent rethrombosis or acute stent thrombosis
● Beta-blocker therapy to prevent recurrent ischemia and life-threatening ventricular
arrhythmias

Then followed by in-hospital initiation of different drugs that may improve the long-term
prognosis:
● Antiplatelet therapy to reduce the risk of recurrent coronary artery thrombosis or, with PCI,
coronary artery stent thrombosis.
● Angiotensin converting enzyme inhibitor therapy to prevent remodeling of the left ventricle.
● Statin therapy.
● Anticoagulation in the presence of left ventricular thrombus or chronic atrial fibrillation to
prevent embolization.
 Therapeutic Objective Pharmacological Non-Pharmacological

● Decreased demand Anti - ischemic therapy Bed rest

ischemia and increase (vasodilators)
oxygen supply ● Nitrates
● Beta - blockers
● Calcium channel
blockers
Supplemental oxygen

● Prevent recurrence Maintenance / Long term Blood pressure control and

therapy
● > 12 months of anti -
ischemic therapy
monitoring
Lifestyle modification
● Smoking cessation
● Healthy diet and
exercise

● Prevent complication Compliance to medications Counseling

Lifestyle modification

● According to a these data suggest that aspirin 150–300 mg should be given to patients
with suspected acute myocardial infarction as soon as possible following the event. The
tablet should be chewed or dispersed in water to achieve a quick onset of its anti-platelet
action

Oxygen
● Arterial hypoxaemia is a frequent occurrence during the first 24 h post-myocardial
infarction and is more common after the use of opiate analgesia.

Nitrates
● Nitrates reduce myocardial workload and hence myocardial oxygen demand by reducing
preload (venodilatation) and afterload (reduced peripheral resistance and blood pressure).
They may also improve myocardial blood flow by coronary vasodilatation although this
has been much debated. Nitrates have been available for over a hundred years and are
still the first-line drugs for relieving acute ischaemic pain.

VASODILATOR THERAPY

Organic Nitrates Uses

Isosorbide Dinitrate ● Angina (sublingual) ● 1st choice for

Isosorbide Mononitrate ● Acute Hypertension vasospastic angina
(IV) ● 2nd choice for
● isosorbide prevention of
mononitrate can be exertional angina
safely used during an ● ADR: headache,
uncomplicated acute dizziness, postural
myocardial hypotension, syncope
 infarction, without the
risk of haemodynamic
deterioration, and
helps to prevent post-
infarction angina.

Ca++ Channel blockers

Dihydropyridine ● Angina ● Preferential arterial

Amlodipine ● Hypertension vasodilation
● 1st choice for
vasospastic angina
● 2nd choice for
prevention of
exertional angina
● ADR: peripheral
edema, and
obstipation
(verapamil)

Beta Blockers

● Atenolol ● Angina ● 1st choice for

● Carvedilol ● Heart failure prevention of
● Hypertension exertional angina
● ADR: bradycardia, AV
block,
bronchospasms,
peripheral
vasoconstriction

ANTIPLATELET AND ANTITHROMBOTIC DRUGS

Aspirin ● Prevention of ● Decrease platelet

thrombotic events (MI, aggregation by
stroke) inhibiting COX - 1
● Acute coronary mediated TXA2
syndrome production