ASSIGNMENT I: CARDIOVASCULAR SYSTEM

Identifying Data: Patient P.B, a 55-year-old male, married, Roman Catholic, an office supervisor
from Lahug, Cebu City was admitted due to sudden onset of severe chest pain

Chief complaint: Chest pain

History of Present Illness:

One hour prior to consult, he experienced crushing substernal chest pain radiating to his left
arm and jaw, associated with shortness of breath, diaphoresis, nausea, and palpitations. The
pain was not relieved by rest or oral analgesics, prompting his family to bring him to the
emergency department.

Past Medical History

• Hypertension, 15 years, poorly controlled.

• Dyslipidemia, 5 years, noncompliant with Atorvastatin 40 mg.

• Cerebrovascular Accident (Ischemic Stroke), 2020, minimal residual deficits.

• Medications: Losartan 100 mg OD only.

• No diabetes mellitus, no prior MI.

Family History

• Father: Hypertension, dyslipidemia, died of MI at 60.

Personal and Social History

• Sedentary lifestyle.

• Occasional alcohol consumption.

• Smoked 3 sticks of cigarettes per day for the past 30 years

Review of Systems

• General: No fever, no weight loss.

• Cardiovascular: Chest pain, palpitations, exertional dyspnea.

• Respiratory: Shortness of breath, no cough with phlegm.

• GI: Nausea, no vomiting or abdominal pain.

 • GU: No dysuria or frequency.

• Neuro: No new weakness, headache, or focal deficits.

Physical Examination

General Survey:

• Middle-aged male, conscious, coherent, in acute distress due to chest pain and dyspnea.

• Not cyanotic, (+) diaphoresis.

Vital Signs:

• BP: 170/100 mmHg

• HR: 110 bpm, regular

• RR: 28 cpm

• Temp: 36.8°C

• SpO₂: 91% on room air

Anthropometrics:

• Height: 165 cm

• Weight: 78 kg

• BMI: 28.7 (Overweight)

Skin/Extremities:

• Warm, moist, clammy.

• Capillary refill < 2 seconds.

• Bilateral pitting edema (+1) on ankles

• No cyanosis or clubbing.

HEENT:

• Pink palpebral conjunctivae, anicteric sclerae.

• No jugular venous distension at rest, (+) JVD on 45° elevation.

• No thyromegaly, no cervical lymphadenopathy.

Chest/Lungs:

• Symmetrical chest expansion.

 • Bibasal crackles on auscultation.

• No wheezes.

Cardiovascular:

• Apical impulse displaced to the 6th ICS, left midclavicular line.

• Tachycardic, regular rhythm.

• (+) S4 gallop, no murmurs.

• Peripheral pulses palpable, slightly weak.

Abdomen:

• Globular, soft, non-tender.

• No hepatosplenomegaly.

• No abdominal bruits.

Genitourinary:

• No CVA tenderness.

• Normal external genitalia.

Neurologic:

• Awake, oriented to person, place, time.

• No new motor weakness or sensory deficits.

• Cranial nerves grossly intact.

• Residual mild right-sided pronator drift (from previous CVA).

At the emergency room the following tests were done:

ECG:

Reading: ST elevation in V1-V6

Test Result Normal Range Interpretation

CBC

Hemoglobin 145 g/L 130–170 g/L (M) Normal

WBC 11.0 ×10⁹/L 4.0–10.0 ×10⁹/L Slightly ↑

Platelets 250 ×10⁹/L 150–450 ×10⁹/L Normal

Cardiac Enzymes

Troponin I 12.0 ng/mL <0.04 ng/mL Markedly ↑

CK-MB 45 U/L <25 U/L ↑

Lipid Profile

Total Cholesterol 260 mg/dL <200 mg/dL ↑

LDL-C 170 mg/dL <100 mg/dL ↑

HDL-C 35 mg/dL >40 mg/dL (M) ↓

Triglycerides 210 mg/dL <150 mg/dL ↑

Test Result Normal Range Interpretation

Blood Chemistry

Fasting Blood
110 mg/dL 70–99 mg/dL ↑
Glucose

BUN 14 mg/dL 7–20 mg/dL Normal

Creatinine 1.0 mg/dL 0.6–1.2 mg/dL Normal

Sodium (Na⁺) 138 mmol/L 135–145 mmol/L Normal

Potassium (K⁺) 4.5 mmol/L 3.5–5.0 mmol/L Normal

ER Management:

• Oxygen supplementation (target SpO₂ >94%).

• Antiplatelet therapy: Aspirin 300 mg + Clopidogrel 300–600 mg loading dose.

• Sublingual Nitroglycerin (symptomatic relief, BP monitoring).

• Morphine IV for chest pain.

• High-intensity statin (Atorvastatin 80 mg).

• Anticoagulation: Enoxaparin or unfractionated heparin.

• IV Furosemide for pulmonary congestion.

• Strict monitoring of vital signs, O₂ saturation, urine output.

Definitive Therapy:

Primary PCI (preferred reperfusion strategy if within 90–120 minutes).

Thrombolysis if PCI unavailable within guideline-recommended timeframe.

QUESTIONS:

1. What are the risk factors of the patient?

2. Given the smoking history of the patient, compute for the number of pack-years
3. What is the difference between Stable Angina and Myocardial Infarction

Tabulate differences based on the characteristics of pain:

a. Onset
b. Location
c. Duration
d. Quality of pain
e. Precipitating factors
f. Relieving factors
4. How does long-standing hypertension and dyslipidemia contribute to the
development of coronary artery disease and stroke?
5. What is the sequence of events in the pathophysiology of myocardial infarction?
6. How does the loss of myocardial tissue after infarction lead heart failure
symptoms?
7. What is the Killip classification of this patient?
8. What is the rationale behind the initial management of acute coronary syndrome,
how do these address the underlying pathophysiology?
a. Morphine
b. Oxygen
c. Nitrates
d. Aspirin

9. Why are dual antiplatelet therapy (aspirin + clopidogrel) and anticoagulation

essential in acute MI management?

10. What is the role of reperfusion therapy (PCI or thrombolysis) in halting myocardial
necrosis, and how does the “golden window” affect outcomes?

11. How do the following drugs modify the pathophysiology of post-MI heart failure and
prevent further remodeling?
▪ Beta-blockers
▪ ACE inhibitors/ARBs
▪ Statins

12. In patients with a history of stroke, what considerations should be made in starting
or adjusting antiplatelet therapy during MI treatment?

13. How do diuretics relieve symptoms of acute decompensated heart failure, and why
must they be used cautiously?