Chest discomfort

Reactor: Dr. Narvas

Moderator: Dr. Santos
Pre-res: Dr. Gonzaga
Specific Objectives:

1. Discuss the Hospital phase management

2. Identify the pharmacotherapy used in ACS
General Data
• MD

• 74 y/o, male

• Married, Filipino, Catholic

• Currently residing 2760, Panaderos St., BRGY 745, Sta. Ana, Manila

• admitted last Jan04-10, 2024 at our institution

Chief complaint
• Decreased in sensorium, chest discomfort
History of present illness
•Patient was admitted 6 days PTA as a case of unstable
angina
•1 day PTA, patient was apparently well upon discharge.

• Until around 9am in the morning patient was noted to

have decrease in sensorium, chest discomfort,
retrosternal hence brought back to our institution
Past medical history
• Known Allergy to Aspirin
• Denies any co-morbidities
• Admitted last Jan 04-10, 2024
Family History
• No heredofamilial diseases noted
Personal and social history
• Non-smoker, non-alcoholic beverage drinker,
denies illicit drug use.
Review of system
•SKIN: No itchiness, no color change, no pigmentation, no rashes

•EYE: No redness, no itchiness, no eye pain, no discharges or excessive lacrimation

•
•EAR: No deafness, tinnitus, or any aural discharges
•
•NOSE: No epistaxis, no nasal discharge, no anosmia
•
•MOUTH: No bleeding gums, no mouth sores
•
•THROAT: No swelling or soreness
•
•NECK: No stiffness, limitation of motion, sensation of lump in the throat, masses or
adenopathies
•
Review of system
•PULMONARY: no cough
•
•CARDIAC: no palpitation, no orthopnea, no platypnea
•
•VASCULAR: No varicosities, no claudication
•
•GASTROINTESTINAL: No dysphagia, no odynophagia, no belching, no heartburn, no
retching, no nausea, no vomiting, no abdominal pain, no melena, no hematochezia, no
diarrhea or constipation

•GENITO-URINARY: No frequency, no urgency, no dysuria, no hematuria, no nocturia, no

flank pain, no urethral discharges
Review of system
•MUSCULO-SKELETAL: No stiffness of the joints, pain and/or swelling. No muscle cramps,
wasting, trauma or abnormal posture.
•
•EXTREMITIES: No cyanosis, no edema, no deformities
•
•ENDOCRINE: No heat-cold intolerance, no polyuria, no polydipsia, no polyphagia
•
•HEMATOPOETIC: No pallor, abnormal bleeding, easy-bruisability or adenopathies
•
•NEUROLOGIC: No headache, no seizures, no numbness, no paresthesia, no dizziness,
•
Physical Examination
Patient came in at the ER in cardiorespiratory distress
•BP: 70/6mmHg CR: irregular RR: 26cpm T: 36.1°C O₂sat: 96%
at room air
•
Skin:
•Skin is moist , warm to touch with good skin turgor.
•
HEENT:
•Anicteric sclerae, pink palpebral conjunctiva, moist lips, oral mucosa and
axilla no cervical lymphadenopathies.
•
Chest and Lungs: No retractions, symmetrical chest expansion, equal tactile
fremitus, dull percussion on both lung base. Noted mid-base crackles on
both lung fields, no bronchopony, egophony or whispered pectoriloquy
Physical Examination
Heart:
•Adynamic precordium. irregularly, irregular rhythm. Apex beat
heard at the 5th ICS, anterior axillary line. The S1 is greater than S2 at
the apex and S2 is greater than S1 at the base. No murmurs were
auscultated.
•
Abdomen:
•Flabby abdomen. Normoactive bowel sounds. Soft and nontender to
light and deep palpation, no palpable masses noted.
•
Extremities:
•No edema, no swelling, no redness, tenderness or limitation in
motion. Full and equal pulses on all extremities.
Salient Features
• Chest Discomfort, Decrease in Sensorium
• 73/M
• Confused
• Hypotension 70/60mmHg
• Tachypnea 26cpm
• Previously admitted as a case of Unstable Angina
• Mid-base crackles
• Irregularly Irregular rhythm

• 12 LECG - AF in CVR, ACS STEMI, anteroseptal wall

• Troponin I negative
Differential Diagnosis
Myocardial Pericarditis Pulmonary
Infarction Embolism
Rule In Retrosternal Retrosternal Chest pain,
chest pain, chest pain tachypnea,
tachypnea hypotension
Rule Out Pleuritic, sharp Cannot totatlly
in charater rule out
 Chest Pain

Cardio Non-Cardio
pulmonary? pulmonary?
 Clinical mainfestation

Harrison’s princples of Internal Medicine 21st edition, Chapter 275: ST Segement Eleveation Myocardial
Infarction page 2054
2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest
Pain
2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest
Pain
Admitting Impression

HCVD, CAD, ACS-STEMI, Anteroseptall wall, Killip

IV, HEART 6, TIMI 5
-
2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest
2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest
Pain
At the ER level
•Jooked to oxygen at 2LPM
•Venoclysed to NE drip: D5W 250cc + NE 32mg to run initially at 30cc/hr, titrated
accordingly.
•Venoclysed with PNNS 1L with a rate of 40cc/hr. L
•Laboratories requested were 12LECG, Troponin I, Na, K, Cl, iCa, Mg, Chest X-ray
PA view, 12 LECG, ABG, CBC, BUN, Creatinine, Na, K, Cl, SGPT, SGOT.
•Activity: Complete bed rest without bathroom privileges

No chest pain day 1, no dypsnea

•Medications started
•Cilostazol 50mg/tab 1 tab BID
•Clopidogrel 75mg/tab 1 tab OD
•Atorvastatin 80mg/tab 1 tab ODHS
•Enoxaparin 0.4cc SQ BID
•Lactulose 30cc ODHS
1st Hospital Day
Subjective Objective Assessment Plan

No chest pain day Awake, alert, not in distress
1, no dypsnea SBP: 120-160 DBP: 70-90 HR: 61-
89 RR: 16-20 Afebrile
Input and Output : 830 vs 800
CBGs: 94, 105, 95
Anicteric sclera, pink palpebral
conjunctiva
Icteric Sclera, Pink palpebral
conjunctiva
No retractions, No adventitious
breath sounds
Adynamic precordium, Normal rate,
regular rhythm
Flabby abdomen, normoactive
bowel sounds, non-tender
No edema
HCVD, CAD, AF in CVR,
ACS-STEMI,
anteroseptal wall, Killip I;
Complicated UTI
Discontinued Norepinephrine
drip. Started Enalapril 5mg/tab
1 tab OD. Noted Leukocytosis.
Requested Urinalysis and
started Ceftriaxone 2g IV OD
Cilostazol 50mg/tab 1 tab BID
Clopidogrel 75mg/tab 1 tab OD
Atorvastatin 80mg/tab 1 tab
ODHS
Enoxaparin 0.4cc SQ BID
Enalapril 5mg/tab 1 tab OD
Lactulose 30cc ODHS
4th Hospital Day
Subjective Objective Assessment Plan

No chest pain day Awake, alert, coherent HCVD, CAD, AF in CVR, Cilostazol 50mg/tab 1 tab BID
4, no dypsnea SBP: 130-160 DBP: 70-90 HR: 69-108 ACS-STEMI, Clopidogrel 75mg/tab 1 tab OD
RR: 16-20 Afebrile anteroseptal wall, Killip I, Atorvastatin 80mg/tab 1 tab ODHS
Input and Output : 1,400vs1,400 Enoxaparin 0.6cc SQ BID
Complicated UTI
Enalapril 5mg/tab 1 tab OD
Anicteric sclera, pink palpebral Ceftriaxone 2g IV OD
conjunctiva Amlodipine 5mg/tab 1 tab OD
Icteric Sclera, Pink palpebral conjunctiva
No retractions, No adventitious breath
sounds
Adynamic precordium, Normal rate,
regular rhythm
Flabby abdomen, normoactive bowel
sounds, non-tender
No edema
7th Hospital Day
Subjective Objective Assessment Plan

Day 7 no chest pain No chest pain day 7, no dypsnea
Awake, alert, not in distress
SBP: 120-140 DBP: 70-90 HR: 61-73
RR: 16-20 Afebrile
Anicteric sclera, pink palpebral
conjunctiva
Icteric Sclera, Pink palpebral conjunctiva
No retractions, No adventitious breath
sounds
Adynamic precordium, Normal rate,
regular rhythm
Flabby abdomen, normoactive bowel
sounds, non-tender
No edema
HCVD, CAD, AF in CVR, Advised Coronary Angiography
ACS-STEMI,
anteroseptal wall, Killip I, 1-2 weeks, encourage the patient to
increase activity by walking about
Complicated UTI
the house and outdoors in good
weather
Normal sexual activity maybe
resumed during this period.
After 2weeks, regulate patient’s
activity base on the exercise
tolerance
May return to work after 2-4weeks
7th Hospital Day
Subjective Objective Assessment Plan

Medications

Cilostazol 50mg/tab 1 tab BID

Clopidogrel 75mg/tab 1 tab OD
Atorvastatin 80mg/tab 1 tab ODHS
Enoxaparin 0.6cc SQ BID
Enalapril 5mg/tab 1 tab OD
Ceftriaxone 2g IV OD
Amlodipine 5mg/tab 1 tab OD
ISMN 30mg/tab 1 tab OD
TMZ 35mg/tab 1 tab BID
Carvedilol 12.5mg/tab 1 tab BID
CONCEPT MAP

Chest Discomfort, Decrease in

Sensorium
73/M
Confused
70/60mmHg
Previously admitted as a case of ACS STEMI, Anteroseptal wall
Unstable Angina
Mid-base crackles
Irregularly Irregular rhythm

12 LECG - AF in CVR, ACS STEMI,

anteroseptal wall
Troponin I negative