Alerta, Kathrinna Feliz F.

MD-MBA 13-0146

General Information
L.O., 57/F, married, Catholic, residing at Kanyugan, Pasig City

Informant
Patient herself, reliability is very good

Chief Complaint
“Examen sa puso” “Kumikirot”

History of Present Illness

The patient has been experiencing intermittent chest pains since 1996. When prompted for the
location, LO exhibited Levine’s sign and pressed her hand to her sternum. The pain lasts from several
minutes to half an hour.

The last episode of chest pain was on August 27.

The chest pain was described as a squeezing (“sumisikip”) and sharp (“tinutusok”) type of pain,
relieved by rest, but not relieved by pain relieving medication. It was aggravated by activity, like
climbing five flights of stairs, and relieved by thirty minutes of rest. The pain was generally precipitated
by physical or psychological stress or hot weather. The pain was not noted to radiate to any other part
but the chest. The severity of the pain is 6 out of 10.

Temporal Profile

x- axis: temporal property of symptom; discontinuous line means intermittent

y-axis: severity of symptom

Review of Systems
LO experiences weakness, dizziness and dyspnea whenever she experiences chest pains. She has
joint pains and joint swelling.

The patient also experiences intermittent palpitations, and has 2-pillow orthopnea. She also
experiences cold intolerance.
Past Medical History
In 1996, patient was taken to the hospital for a fainting episode, precipitated by chest pain, dyspnea
and palpitations. The symptoms were associated with physical and psychological stress, and hot
weather. It was found that LO had recurrent sore throat prior to the hospitalization. Diagnostic workup
was done and she was diagnosed with Rheumatic Heart Disease.

LO took the following medications for the RHD for the next five years, then stopped, against
physician’s orders. It must be noted, however, that the patient did not give any dosages.
 Prednisone
 Isordil
 Penadur
 Aspirin

LO had the following procedures done on 1996 when she had a work up:
 2D echo
 ECG
 Blood tests
 Throat swab

She also had an operation for cataract correction on two separate instances: 2008 for the left eye,
and 2009 for the right.
LO also experienced vertigo in March.

The patient is currently taking the following medications:

 Aspirin
 B-complex
 MX3
 My marvel tahibo

Family History (Genogram)

The patient is 2nd eldest of 13 children. She is married to Danilo Opiado and they have two sons,
the younger having already established a family. The older son is currently unemployed, but finds
contractual work now and again.
Personal/Social History
There were no immunization protocols, yet, when the patient was born. LO claims not have had any
immunizations.
LO is a high school graduate. She does not smoke, does not drink alcohol and does not engage in
illicit drug use. She exercises zumba, twice a week of one hour duration each. She drinks coffee twice
a day, one in the morning and one in the afternoon and tea during lunch.

LO is a volunteer health worker, who works on Wednesdays from eight in the morning to five in the
afternoon. She lives in a compound with two houses, with electricity and good water supply (nawasa).
The family uses an outdoor stove, so LO is exposed to smoke when they cook. She is also exposed
to third hand smoke from his son.

Reproductive and Obstetric History

LO had her menarche at the age of 12, her first coitus at 19 and she has only had one sexual partner
since then. She does not use any contraceptives and has no sexually transmitted disorders.

Her obstetric score is G2P2 2002.

Stakeholder Analysis

Name Stake Stand Intensity Degree of Insight/Action

of Stand Influence
LO She needs to get Ally High High She does not want her
better family to know when she is
not well; does all the
housework
Husband Left in the house Ally High High Unemployed, also ailing,
with LO, possible may need to be taken care
caretaker of, too
Child 1 Financer Ally High High Main financer
Child 2 Financer Ally High High Has a family, limited finance
responsibility
Mother Lives in a Ally High Moderate LO already independent of
separate parents
compound
Father Lives in a Ally High Moderate LO already independent of
separate parents
compound
Grandchildre LO takes care of Ally High Moderate Child 2 must be ready to
n from Child 2 them take on the weight LO has in
taking care of these children
Coworkers LO confides in Ally High High The ones who know about
them; they were LO’s ailments because she
the ones who only confides in them
took her to the
hospital in 1996

Physical Exam Findings

Anthropometrics Vital Signs
Height: 1.57m HR: 70 Pain Scale: 6/10
Weight 61 kg RR: 12
BMI: 24.8 T: 34.2 degC
BP: Reading 1: 150/100
 Reading 2: 165/80

Head and Neck (-) ear discharge, no palpable lymph nodes, no discolorations in throat
and tongue
Eyes R: 20/20; L: 20/25; normal fundoscopic findings, IOP normal
Cardiovascular JVP: 7.5 cm, (-) carotid bruits, (-) murmurs, PMI 5th ICS MCL
Breasts and Not indicated
Axillae
Chest and Lungs Adynamic precordium, symmetrical tactile fremitus and chest expansion
Back and spine Not indicated
Abdomen (+) striations, (-) guarding, (-) bruits, (-) tenderness, (-) hepatomegaly, (-)
splenomegaly
Pelvis/ GU Not indicated
Rectal Not indicated
Upper Ex (-) pallor, (-) peripheral cyanosis, (-) edema, pulses are equal, visible
Lower Ex and palpable nodules in distal joints in the upper ex and metatarsal
joints of lower ex
Integumentary
Skin No remarkable findings
Nails No remarkable findings
Hair and scalp No remarkable findings

Primary Impression

Acquired past medical history suggests rheumatic heart disease. The chest pain might have been
caused by ischemia of the heart from the increased metabolic requirement of an enlarged left atrium
due to the mitral stenosis. However, the physical exam findings contradict the history with the lack of
murmurs heard on auscultation. LO also does not show any signs of difficulty moving, and she still
moves briskly. These findings are not consistent with a 19-year RHD, mostly unmedicated.

Given the patient’s chief complaint of intermittent chest pain precipitated by physical and
psychological stress and the acquired BP measurements, the patient may have coronary artery
disease with hypertension.

Pathophysiology
Atherosclerosis is the underlying mechanism in coronary artery disease and can be one of the
factors affecting hypertension.

For coronary artery disease, atherosclerosis narrows the coronary arteries, decreasing the supply
of oxygenated blood to myocytes, especially during times of augmented oxygen requirement, like
exercise. This causes underperfusion and, possibly, subsequent ischemia. The ischemia can be the
cause for chest pain, and the fact that there is a more palpable change in perfusion ratios during
increased activities underlies the reason or the pain being precipitated by stress, whether physical or
psychological.

Atherosclerosis may also aggravate hypertension. The sclerosis is not limited to the vessels of the
heart, and in fact may affect any vessels in the body. The same concept of narrowing of the vessels
may happen in the peripheral circulation, thus increasing the tension within the vessels. Increased
tension requires increased blood pressure for the blood delivery system to be more effective.

Consequently, the left ventricle, the primary chamber of the heart responsible for the systemic
circulation, will have to work harder to pump blood through vessels affected by atherosclerosis. It’s
also possible for the left ventricle to already be slightly hypertrophied, which would worsen the
narrowing of the coronary vessels, and aggravating the CAD.

Additionally, LO is also postmenopausal. At this stage, atherogenic risk factors increase and the
risk of developing CAD also increases.
Differential Diagnosis

Rheumatic heart disease

The patient’s history is highly indicative of rheumatic heart disease. LO experiences recurring
episodes of sore throat before 1996 when she had the episode of syncope, losing consciousness, and
requiring medical attention. The fainting episode could have been caused by ischemia of the heart
from the worsening mitral stenosis, or severe carditis that may manifest with rheumatic fever.

The patient, however, did not present with murmurs when auscultated, and with a 19-year history
of mitral stenosis, the classic presentation of RHD, also considering the fact that the patient is not on
any medication, it seems unlikely for there to be RHD. Unmedicated, long standing mitral stenosis
would lead to atrial fibrillation, which is definitely contradictory to the level of activity the patient claims
to be able to do on a weekly basis.

Essential Hypertension
The blood pressure taken from the patient was consistently high during the start and the end of the
physical exam. Although the patient claims that her normal blood pressure is 90/60, it seems unlikely
when the two pressure readings during the clinical interview registered significantly high results.

At LO’s age, it is possible for her to have hypertension, a multifactorial disease that could have
developed throughout the years. Given LO’s age, and the progressive nature of hypertension through
atherosclerosis (already discussed), the patient may have an advanced case of hypertension, where
the heart is already enlarged and the hypertrophy is causing the ischemia, which would explain the
chest pains.

However, the PMI was noted to be in the 5th ICS MCL, and that usually indicated a non-enlarged
heart. Hypertension without significant heart enlargement or comorbid myocardial ischemia will not
manifest with chest pain.

Unstable Angina Pectoris

Exertional angina is associated with a limitation in activity due to the amount of effort the heart will
have to exert, and the failure to compensate the amount of supply of oxygen to the demand. There
should be a very predictable threshold for the patient, which marks how severe the angina already is.

The patient claims to feel chest pains when she has either physical or psychological stress. The
patient described physical stress as walking up five flights of stairs and this is followed by 30 minutes
of rest before she is able to exert any more effort into moving.

The characteristic of the pain is also consistent with angina pectoris, with the patient exhibiting
Levine’s sign by placing her hand over her sternum when asked where the pain is located. The
patient also wakes up in the middle of the night with dyspnea, which can also be a presentation of
angina pectoris.

Exertional angina typically only needs 1-5 minutes of rest, however and the patient needs 30
minutes of rest to recover from her activity.

However, when asked about her reaction to an hour-long zumba activity, she only reports
tachypnea (“hinihingal”), and no chest pain.

Problem List

1. Coronary Artery Disease

2. Hypertension
3. Joint Pains
a. Gout

Management
The following tests should be conducted to confirm or rule out the primary impression and consider
also, the differentials:
  Echocardiogram – to check for valvular lesions
 Electrocardiogram – to check for valcular abnormalities and chamber enlargements
 Stress test
 CBC – for the electrolytes
 Urinalysis – check for proteinuria, primarily so the medications prescribed are sure not to
have any contraindications to the patient.

Once diagnosis is confirmed, the first thing to do is to reassure the patient, and educate them on
what CAD is. From the state of the patient, she is very nearly asymptomatic, except for episodes of
chest pains that are not consistent with activity. They must be advised on the disease progression
and on what to expect as she ages.

The same should be done with hypertension. The patient is an asymptomatic hypertensive,
assuming that the chest pains are related to the CAD. Aside from decreased tolerance for high
exertion activities, the patient shows no other signs of hypertension. She must be educated about the
progressive nature of the disease and the fact that it is a lifelong management track that she is
looking at. Furthermore, the patient should be informed that it is a lifestyle change that is needed to
manage CAD and hypertension.

Pharmacological management involves mainly treating the hypertension, as it is the aggravating

factor for the CAD. To reduce the risk of prescribing several medications, the patient should first be
titrated with one drug, a diuretic. After a few weeks of checkup, seeing the patient once every week
and adjusting the dosage of the drug, if the change in BP is still inadequate, a second drug may be
prescribed, a beta-blocker or a calcium-channel blocker.

Aspirin should also be given to decrease the possibility of the patient having coronary events.

All these medications are covered by PhilHealth, so it would also be prudent to encourage the
patient to enroll.

An increase in exercise may also be applicable. The duration may be decreased from an hour to
half an hour, but it should be done at least 5 times a week, or everyday if the patient can manage it.
Brisk walking for 30 minutes everyday will suffice. Encourage the patient to take her husband with him
so it would be an undertaking for the both of them instead of just the patient.

A change in diet is also imperative. The patient should be advised to decrease fat and salt intake,
and increase the portion for vegetables in every meal.

Because CAD and HTN have genetic components, the same lifestyle changes may be advised for
the whole family, to not only involve them in the regimen for the patient, but also improve the health of
the other members of the family.

Lastly, gout medication should be given to address the nodules in her distal phalanges and
metatarsal joints. Pain medication for the arthritis may also be given.