Ferdinand B. Sta. Ana, Jr.

2012-24716
HISTORY

Identifying Data

Name: Nilda Caragay

Age: 71
Status: Married
Occupation: Mananahi (Retired), Household work
Residence: Pandacan, Manila
Province: Laguna

Chief Complaint: Mabigat at kumikirot ang dibdib

History of Present Illness:
Onset: Sudden
Progression: intermittent
Quality: Constricting, heavy
Radiation: Epigastric, neck, back, arms
Severity: 10/10
Duration: Hours
Associated symptoms: dyspnea
May 12, 2014
Fatigued due to outing
Abrupt heaviness in epigastric area which radiated upward, chest,
neck, and back
Severity: 10/10
Was brought to PGH ICU
Was given 3 sublingual nitrates (isodryl)
o Pain alleviated in other aread while there was residual pain in
chest area
Was diagnosed with Sick Sinus Syndrome
Was also medicated with Losartan, Captopril and Clopidogrel
Labs: cTnI, 2D Echo, Ultrasound, CXR
o CXR impressions: cardiomegaly, pulmonary congestive
changes, atherosclerotic aorta
May 26, 2014
Surgically operated to put pacemaker; discharged 2 days after
1st Week of June 2015
N.C. was admitted to PGH for angina and stayed for 5 days
There was abrupt heaviness in epigastric area which radiated upward
and to the chest, neck and back
Severity: 10/10
Was given 3 sublingual nitrates (isodryl)
o Pain alleviated in other aread while there was residual pain in
chest area
Labs: cTnI, 2D Echo, Ultrasound, CXR
o CXR impressions: cardiomegaly, pulmonary congestive
changes, atherosclerotic aorta
September 27, 2015
N.C. was admitted to PGH for angina

There was abrupt heaviness in epigastric area which radiated upward

and to the chest, neck and back
Severity: 10/10
Was given 3 sublingual nitrates (isodryl)
o Pain alleviated in other aread while there was residual pain in
chest area
Currently waiting for angiogram and angioplasty
Medications:
Medicine
Dosage
Enalapril
5 mg, 2x a day
ASA (aspirin)
80 mg, once a day
Atorvastatin
8 mg, once a day
Isosorbide mononitrate
30 mg, once a day
Metformin
500 mg, 2x a day
Clopidogrel
75 mg, once a day
Carvedilol
12.5 mg, 2x a day
MX3
50 mg, once a day
Omeprazole
40 mg, once a day

Past Medical History

Surgical: had previous cholecystectomy

Obstetric
o G11P10(10, 0, 1, 10)
o Pre-eclampsia in last pregnancy (29 yrs old)
Medical
o Hypertension since last pregnancy
o Hyperglycemia: glucose levels reaching 250

Family History

Hypertension from both maternal and paternal sides

Brother died from MI at 32 yrs old; Parents also died from MI
No diabetes
No cancer
No TB

Personal and Social History

Has 10 living children

Smoked for 2 months some years ago
Son also smokes but does it outside the house
Drinks alcoholic beverages occasionally
Mahilig kumain ng matataba (e.g. chicharon)
Laging nilalagyan ng Maggie Magic Sarap ang pagkain

Review of Systems
General

HEENT

(-) polyuria
(-) nocturia
(-) tea-colored urine
(-) dysuria
(-) difficulty/pain in urinating
(+) edema

Respiratory
Cardiovascular

GIT

Urinary

Extremities
Skin

PHYSICAL
EXAM

(-) joint pain or swelling

(-) clubbing
(+) dyspnea
(-) cough
(-) colds
(+) angina
(+) PND
(+) orthopnea
(-) palpitations
(+) abdominal pain (epigastric)
(-) vomiting
(-) diarrhea
(-) constipation
(-) flatulence
(-) melena
(-) hematochezia
(-) hematemesis
(-) polyuria
(-) nocturia
(-) tea-colored urine
(-) dysuria
(-) difficulty/pain in urinating
(+) edema
(-) joint pain or swelling
(-) clubbing
(-) jaundice
(-) pallor
(-) cyanosis
(-) petechiae
(-) ecchymoses

Vital Signs

Temperature: was not able to measure

Pulse Rate: 60 bpm
Respiratory Rate: 22 breaths / min
Blood Pressure: 116/62

Neck Examination

JVP = 2 cm H2O at 300

o CVP = 7 cm H2O at 300
Full and equal carotid pulses
(-) carotid bruits

Inspection

No Precordial Bulge
PMI at 5th ICS LMCL

Palpation

Apex beat at 5th ICS LMCL

No heaves, thrills or lifts

Percussion
3

Cardiac Area of Dullness noted 8 cm from the Midsternal Line to 5th

ICS LMCL

Auscultation

Normal Rate
Regular Rhythm
No S3, No S4, No Murmurs

Extremities

DIFFERENTIAL
DIAGNOSIS

PRIMARY
WORKING
IMPRESSION
LABORATORY/
WORK-UP
PATHOPHYSIOLO
GY

MANAGEMENT

Pulse Rate for all pulse sites (Brachial, Radial, Femoral, Popliteal,
Posterior Tibial, Dorsalis Pedis) are 64 bpm with normal amplitude.
Similar in volume and rhythm bilaterally.
No cyanosis, clubbing and bipedal edema observed

Aortic dissection
Acute myocardial infarction
Esophageal reflux

Non-ST-segment Elevation Acute Coronary Syndrome

12-lead ECG
Serial measurement of cTnI separated by a certain number of hours depending
on sensitivity of assay used
Four processes:
1) Rupture of unstable atheromatous plaque
Leads to formation of typically nonocclusive superimposed
thrombus with subsequent impaired myocardial perfusion
2) Coronary arterial vasoconstriction
3) Imbalance between the supply and demand of the myocardium for
oxygen
4) Gradual intraluminal narrowing of an epicardial coronary artery
Reference: Mann, Zipes, Libby, Bonow and Braunwald. (2014). Braunwalds
heart disease: A textbook of cardiovascular medicine (10th ed). Philadelphia, PA:
Saunders.
Diuretic
Beta blockers