MORBIDITY

CONFERENCE
 OBJECTIVES
To present and a discuss a case of a psychiatric patient with Acute Coronary
Syndrome.

To discuss the approach on a patient presenting with chest pain. 

To identify the dilemma and problems encountered in the case.

To discuss the ethical, psychosocial, and legal aspects of a psychiatric patient with medical
conditions.
Timeline of past events c/o FM
 COURSE IN THE WARD 
April 1, 2022 (12:18 pm)

S O A P
• Chest pain • Vital signs: • To consider • ECG
• BP: 100/70 Acute Coronary • Sinus
Syndrome  Tachycardia,
• HR: 105 Inferior and
anterior ST T
• RR: 20 wave
• T: 36.5 deg C abnormality
• O2sat: 98% • Trop I
• CKMB
 COURSE IN THE WARD 
April 1, 2022 (3:30
pm)

S O A P
• Sternal pain • Vital signs: • Acute Myocardial • Transfer to JBL
• 1/10 • BP: 110/70 Infarction  for further
• HR: 103 evaluation and
management
• Awake,
conversant • Refer to MSW to
inform relative 
• Good appetite
• Trop I
(qualitative):
positive
• CKMB: 38
 COURSE IN THE WARD 
April 7, 2022 

S O A P
• No subjective • Stable vital signs • Ischemic Heart • Home Medications:
complaints Disease • Aspirin 80 mg  1 tab OD
anteroseptal wall • Clopidogrel 75 mg 1 tab OD
NSTEMI sinus, • ISMN 30 mg 1 tab OD
NYHA • Atorvastatin 80 mg, 1 tab OD
• Hypertension • Carvedilol 25 mg ½ tab OD
Stage 2 • Losartan 50mg 1 tab OD
controlled • Biperiden 2mg 1 tab OD
• Risperidone 2mg ½  tab OD
• Undifferentiated
• For 2d Echo
Schizophrenia
 COURSE IN THE WARD 
April 8, 2022 

S O A P
• No subjective • Stable vital signs • Ischemic Heart •  Risperidone
complaints Disease increased to 4
anteroseptal mg ½ tab BID
wall NSTEMI
sinus, NYHA
• Hypertension
Stage 2
controlled
• Undifferentiated
Schizophrenia
 COURSE IN THE WARD 
April 21, 2022 (8:40 am)

S O A P
• Diagnostics:
• Chest pain • Vital signs: • Acute Coronary • ECG:
• BP:170/100 -> Syndrome
• Midsternal  • ST depression, Anteroseptal,
120/90 Lateral wall
• 10/10 • HR: 125 secondary to • CKMB
• Occurred at • T: 37.5 Unstable • Trop I
• CBC
rest • RR: 22 angina, Ischemic • Lipid profile
• O2sat: 99% • RBS
• Conscious, coherent in
Heart Disease, • BUN, Crea, Na, K, Cl, SGPT, SGOT, BUA
• Diaphoretic  cardiac distress Coronary Artery • D5W 1L x KVO
• ISDN 5 mg SL X 2 doses
• Adynamic precordium, Disease   • Aspirin 80 mg tab 4 tabs now 
tachycardic, regular • O2 via facemask at 10 lpm 
• Psych meds on hold
rhythm, no murmurs • Placed on high back rest with no BRPs
• Levine's sign  • Transfer to JBL
 April 21, 2022 CBC

CKMB 21 Hgb 10.90

Trop I negative Hct 33.4

Na 130.1 WBC 14,250

K 4 Neutrophils 84.5

Lab Results  Cl 98.2 Lymphocytes 10.9

BUN 17.79 Eosinophils 0.4

Crea 1.10 Platelet 326,000

BUA 5.83

SGPT 22.6

SGOT 19.5
 COURSE IN THE WARD 
April 28, 2022 (7:02pm)

S O A P
• No subjective • Stable vital signs • Acute Coronary • Home Medications:
complaints Syndrome • Aspirin 80 mg  1 tab OD
secondary to • Clopidogrel 75 mg 1 tab OD
• ISMN 30 mg 1 tab ODHS
Unstable angina, • Atorvastatin 80 mg, 1 tab OD
Ischemic Heart • Carvedilol 6.25 mg ½ tab BID
Disease, Coronary • Losartan 50mg 1 tab OD
Artery Disease   • Omeprazole 40 mg 1 tab OD
• Hypertension • Lactulose 30cc ODHS
• ISDN 5mg TID PRN for chest
stage 2
pain
• Undifferentiated
schizophrenia
 COURSE IN THE WARD 
April 28, 2022 (10:18pm)

S O A P
• Bruising left arm • Hematoma, Left arm • Hematoma, left • Cold compress on the area
• Denies • Hyperpigmentation arm • Referred to OB:
trauma and scaling over • DX: Diaper dermatitis,
vaginal area skin tag on the inner
• Mass at inner aspect • T/C diaper aspect of the right thigh
of thigh, right dermatitis • Mgt:
• 2x2 • T/C skin tag • Silver sulfadiazine
pedunculated BID
• Non-tender • Betadine feminine
• No active wash BID
bleeding • Regular perineal
hygiene
 COURSE IN THE WARD 
April 29, 2022 (1:30 am)

S O A P
• Chest heaviness • Vital signs: • Acute Coronary • Diagnostics:
• BP: 110/70 Syndrome • ECG
• HR: 90 secondary to • Anteroseptal and
Unstable angina, Lateral ST T wave
• RR:21
Ischemic Heart abnormality
• T: 37.1 Disease, Coronary • ISDN 5 mg tab now
• O2sat: 94% Artery Disease 
 COURSE IN THE WARD 
April 29, 2022 (2 am)

S O A P
• Persistence of • Vital signs: • Acute Coronary • ISDN 5 mg tab
chest heaviness • BP: 130/90 Syndrome now (2nd dose)
• HR: 87 secondary to
Unstable angina,
• RR:19
Ischemic Heart
• T: 37.1 Disease, Coronary
• O2sat: 98% Artery Disease 
 COURSE IN THE WARD 
April 29, 2022 (2:41 am)

S O A P
• Decreased chest • Vital signs: • Acute Coronary • Diagnostics:
heaviness • BP: 120/90 Syndrome • CKMB, Trop I
• HR: 83 secondary to • ISDN 5 mg tab
Unstable angina, now (3rd dose)
• RR:19
Ischemic Heart
• T: 36.9 deg C Disease, Coronary
• O2sat: 99% Artery Disease 
 COURSE IN THE WARD 
April 29, 2022 (2:45 am)

S O A P
• Dry cough, • Vital signs: • T/C COVID-19 • Diagnostics:
phlegm infection • COVID-19 RTPCR
• BP: 130/70 • CBC
• No fever • HR: 83 • Na, K
• RR:19 • chest xray once
• O2sat: 99% stable
• Place on high back
• Symmetrical chest rest
expansion, clear • Complete bed rest
breath sounds, no w/o BRPs
• Retrieve all lab results
rales, no wheezes
and medical abstract
from JBL to include
discharge summary
 April 29,2022 CBC

CKMB 16 Hgb 9.9

Trop I negative Hct 30

Na 127.7 WBC 10,660

K 2.63 Neutrophils 64.9

Lab Results  Lymphocytes 23.5

Eosinophils 1.7

Platelet 231,000
 COURSE IN THE WARD 
April 29, 2022 (3:10 pm)

S O A P
• No chest pain • Vital signs: • Electrolyte • KCl tab 1 tab TID x
• No DOB • BP: 140/80 Imbalance, 5 days
• HR: 89 hypokalemia, • Refer to NDU for
hyponatremia liberal salt
• RR:18 • Anemia prob IDA • Transfer to JBL
• T:36.5 deg C • Acute Coronary
• O2sat: 98% Syndrome
• Hgb:9.9 secondary to
• Na: 127.7 Unstable angina,
• K: 2.63 Ischemic Heart
Disease, Coronary
Artery Disease 
 COURSE IN THE WARD 
May 9, 2022 (12: 49 am)

S O A P
• No subjective • Vital signs: • Ischemic Heart
Disease, Unstable
• Home Medications:
complaints • BP: 140/80 • Aspirin 80 mg  1 tab OD
• HR: 81 angina Braunwald • Clopidogrel 75 mg 1 tab OD
Class IIB-2, • ISMN 30 mg 1 tab ODHS
• RR: 20
Ischemia sinus not • Atorvastatin 80 mg, 1 tab OD
• T: 36.5 deg C in failure • Carvedilol 6.25 mg 1 tab BID
• O2sat: 98% • Undifferentiated • ISDN 5mg TID PRN for chest
schizophrenia pain
• Trimetazidine 35 mg 1 tab
BID
• Enalapril 5 mg 1 tab OD
 COURSE IN THE WARD 
May 11, 2022 ( 2pm)

S O A P
• Cough for 2 • Vital signs: • Hospital Acquired • Diagnostics:
weeks • BP: 130/80 Pneumonia  • Chest xray
• No fever • HR: 96 • CBC
• Ampicillin
• RR: 14
Sulbactam 1.5 gm IV
• T: 36.1 deg C q6 for 7 days
• O2sat: 98% • Clarithromycin 500
• Symmetrical chest mg tab BID x 7 days
wall expansion, • NAC 600 mg tab
fine crackles R>L, ODHS X7 days
occasional rales, • High back rest
expiratory wheezes • O2 at 5 Lpm
 May 11, 2022

Hgb 9.8

Hct 32

WBC 9,780

Lab Results  Neutrophils 86.8

Lymphocytes 8.1

Eosinophils 0.5

Platelet 238,000
 COURSE IN THE WARD 
May 11, 2022 ( 2pm)

S O A P
• Cough for 2 • Vital signs: • Hospital Acquired • Diagnostics:
weeks Pneumonia  • Chest xray
• BP: 130/80 • CBC
• No fever • HR: 96 • Na, K
• Dyspnea
• RR: 24 • SGPT
• Crea
• T: 36.1 deg C
• sputum GSCS
• O2sat: 98% • Blood GSCS x 2 sites
• Symmetrical chest • Ampicillin Sulbactam 1.5
wall expansion, gm IV q6 for 7 days
• Clarithromycin 500 mg
fine crackles R>L, tab BID x 7 days
expiratory wheezes • NPO
• CBG q8
 COURSE IN THE WARD 
May 11, 2022 ( 2pm)

S O A P
• 4x4 cm partial • Grade II decubitus • Diagnostics:
thickness skin ulcer, gluteal area • Wound GSCS
loss with
purulent
discharge over
gluteal area
 COURSE IN THE WARD 
May 11, 2022 ( 8pm)

S O A P
• Difficulty • Vital signs: • Hospital Acquired • Diagnostics:
breathing • BP: 170/90 Pneumonia  • ECG: Sinus
• HR: 104 tachycardia,
anteroseptal wall
• RR: 24
infarct
• T: 36.3 deg C • O2 inhalation at 8 lpm
• O2sat: 95% • Ampicillin Sulbactam
• Symmetrical chest shifted to Piperacillin-
wall expansion, fine Tazobactam 4.5 gm IV
crackles R>L, q6
expiratory wheezes • Maintain moderate
• Cold and clammy High back rest
extremities • Transfer to JBL
 COURSE IN THE WARD 
May 17, 2022 ( 8pm)

S O A P
• No subjective • Stable vital signs • Hospital Acquired • Home Medications:
• Sultamicillin 750 mg 1 tab
complaints Pneumonia  OD x 5 days
• Ischemic Heart • Omeprazole 40 mg OD x 7
days
Disease, Unstable • Aspirin 80 mg  1 tab OD
angina Braunwald • Clopidogrel 75 mg 1 tab OD
• ISMN 30 mg 1 tab ODHS
Class IIB-2, • Atorvastatin 80 mg, 1 tab OD
Ischemia sinus not • Carvedilol 6.25 mg 1 tab BID
• ISDN 5mg TID PRN for chest
in failure pain
• Undifferentiated • Trimetazidine 35 mg 1 tab BID
• Enalapril 5 mg 1 tab OD
schizophrenia • Lactulose 30 cc ODHS
• KCL tab 2 tabs 5x daily x 10
days
• Ff-up with JBL via teleconsult at JBL
• Psych medications continued
 COURSE IN THE WARD 
May 17, 2022 ( 8pm)

S O A P
• No subjective • Stable vital signs • Hospital Acquired • Home Medications:
• Sultamicillin 750 mg 1 tab OD x 5 days
complaints Pneumonia  • Not available
• Ischemic Heart • Shifted to Co-Amoxiclav 625
mg TID x 7 days
Disease, Unstable • Levofloxacin 500 mg OD x 5 days
angina Braunwald • Omeprazole 40 mg OD x 7 days
• Aspirin 80 mg  1 tab OD
Class IIB-2, • Clopidogrel 75 mg 1 tab OD
• ISMN 30 mg 1 tab ODHS
Ischemia sinus not • Atorvastatin 80 mg, 1 tab OD
in failure • Carvedilol 6.25 mg 1 tab BID
• ISDN 5mg TID PRN for chest pain
• Undifferentiated • Trimetazidine 35 mg 1 tab BID
•
schizophrenia •
Enalapril 5 mg 1 tab OD
Lactulose 30 cc ODHS
• KCL tab 2 tabs 5x daily x 10 days
• Ff-up with JBL via teleconsult at JBL
• Psych medications continued
 COURSE IN THE WARD 
May 18, 2022 ( 2pm)

S O A P
• cough • Crackles left lung • Hospital Acquired • Diagnostics:
Pneumonia  • Sputum GSCS
field •
• Ischemic Heart Oral antibiotics continued
Disease, Unstable
angina Braunwald
Class IIB-2,
Ischemia sinus not
in failure
• Undifferentiated
schizophrenia
 COURSE IN THE WARD
May 24, 2022 ( 9:50am)
S O
• Decreased cough,
unproductive
• No DOB
• No chest pain
• Fair appetite
 
A P
• Hospital Acquired • Diagnostics:
Pneumonia  • CBC
• Ischemic Heart • Crea
Disease, Unstable • Na, K, Mg, SGPT, BUN, crea,
total calcium
angina Braunwald
• Albumin
Class IIB-2, • Trop I, CKMB
Ischemia sinus not • Chest xray AP High sitting
in failure • O2 support decreased to 2 Lpm
• Undifferentiated
schizophrenia
 May 24, 2022 CBC

CKMB 18 Hgb 10.90

Trop I Negative Hct 33.4

Na 135.3 WBC 14,250

K 4.68 Neutrophils 84.5

Lab Results  BUN 12.16 Lymphocytes 10.9

Total Ca 1.93 Eosinophils 0.4

Mg .79 Platelet 326,000

Albumin 29

Crea 0.82

SGPT 35.5
 May 24, 2022

Chest Xray Pneumonia right

Fibrotic residuals
Lab Results 
 COURSE IN THE WARD 
May 24, 2022 (5:30 pm)

S O A P
• Electrolyte • Diagnostics:
Imbalance, • Repeat Tot Ca, Albumin after
Hypocalcemia one week
• Hypoalbuminemia • CaCO3 500 mg OD started
• Referred to nutritionist for
• Hospital Acquired
nutritional build up
Pneumonia  • Revise diet to low salt and low fat
 COURSE IN THE WARD 
May 26, 2022 ( 12:45pm)

S O A P
• Occasional cough • Clear breath • Hospital Acquired • Diagnostics:
Pneumonia Resolving • Repeat chest xray PAL after 2
sounds
• Malnutrition weeks
• Wt: 45 kg -> 38kg • Ensure supplementation
• BMI • Weight monitoring every 15 days
 COURSE IN THE WARD 
May 31, 2022 ( 7:31pm)

S O A P
• Total Calcium: 2.01 • Electrolyte Imbalance, • CaCo3 continued
• Albumin: 35 Hypocalcemia
• Hospital Acquired
Pneumonia Resolved
• Malnutrition
 COURSE IN THE WARD 
June 14, 2022 ( 12:10pm)

S O A P
• No dyspnea • Stable vital signs • Electrolyte Imbalance • Transferred to Female ward
• No shortness of Resolved
• Hospital Acquired
breath Pneumonia Resolved
• No chest pain • Decubitis Ulcer, Grade II
• No desaturations • Ischemic Heart Disease,
• Ambulatory Unstable angina
Braunwald Class IIB-2,
Ischemia sinus not in
failure
• Malnutrition
• Undifferentiated
schizophrenia
DISCUSSION
 The Patient
Risk for IHD
Male gender
Increasing age Jan3 2012,Jan 5,2012,Oct 24,2012
Hpercholesterolemia
BP=150/110,140/90,180/110
Hypertension
menopause Metoprolol 100mg1/2 tab od
Cigarette smoking Increase d to 100 mg tab od
Diabetes Mellitus
Obesity
Sedentary lifestyle
Genetic factors?
Family history of premature IHD (male <55 yo,female <65 yo)
Early stage of atherosclerosis- breakdown of endothelial
Tissues,fatty streak ,plaque)

Start of endothelial dysfunction

Patient during this time September17 2017,
Has started to have BP elevation Still with episodes of BP elevation Metoprolol shifted to losartan
No chest pains Chest pain occurred(angina) 50mg tab od
(builds up of plaque)
Endothelial damage

December 23, 2017 Narrowing of artery enough to cause O2 deprivation ISCHEMIA

ECG changes :ST depression

2018 – CXR: Atheromatous Aorta(hardening and narrowing of the coronary arteries,diminish elasticity)
that progress with age due to Atherosclerosis
Late stage of Atherosclerosis forming thick plaque April 1,2022 –MYOCARDIAL
Due: overtime deprivation of oxygen INFARCTION(heart Attack)
Obstruction of the artery (plaque rupture and blood clot formation
to heart muscle/tissue death
75 y.o female patient
Known hypertensive since 2012
menopause
Sedentary lifestyle
Presented with chest pain Substernal occurred at rest,
levine’s sign Diagnosis: Acute Coronary Syndrome 2° to Non STEMI
PE: conscious,coherent in cardiac distress
BP=100/70 HR=105 RR=20 T=36.5 02 sat 95%
Tachycardic

ECG:ST depression
Elevated biomarkers: Troponin I (+)
CK MB elevated at 38 (0-24 Iu/L
CXR: Atheromatous Aorta
 TIMELINE

2012 2018
BP ELEVATIONS
Hypertension 2022
Chest pains MYOCARDIAL INFARCTION
Ischemia
Atheromatous
Aorta 2020
2017
Hypertension
Frequent
Chest pain Recurrence of chest pain
ST depression (ECG)
Problems and dilemmas encountered
• Limitations of resources.
• Proper coordination and update from the hospital where the patient was transferred.
• What would be the psychological impact on a patient who is repeatedly transferred
to another institution without significant others?
• What are the problems encountered in locating patient’s relatives. How do we deal
with difficult relatives who refuse to take care of the patient.
• What are the fundamental and basic rights of a mentally ill patient?
• Who gets to decide in place of a psychiatric patient without relatives needing
consent in emergency situations?
• How valid is the consent from a psychiatric patient?
• What are the legal implications in handling psychiatric patients and how can doctors
be protected from lawsuits.
Nursing Service
Psychiatry Service
MSW
Psychology Unit
Legal Service
 Working diagnosis
Ischemic Heart Disease, Unstable angina Braunwald Class IIB-2,
Ischemia sinus not in failure
Cataract, OU
Undifferentiated schizophrenia
Learning points
1. There is no substitute for a good history and PE despite limitation of resources
2. Proper and good coordination with other hospitals can help a lot in saving lives.
3. Family support is crucial most especially during critical times
4. As doctors we should treat the patient holistically. Take into consideration not
only the medical aspect but also the social, psychological and legal aspects.
Take Home Message