The Silent Killer

GUBATAN, TOLENTINO, VIZCARRA

CASE PRESENTATION
CASE PRESENTATION

GENERAL DATA
▸ MPG

▸ Female, 58 years old

▸ Caloocan City

▸ Filipino

▸ Roman Catholic

▸ Date and Time of Admission: June 3, 2019 - 3:19AM

▸ Cocolife
CASE PRESENTATION

DIZZINESS
Chief Complaint
CASE PRESENTATION

HISTORY OF PRESENT ILLNESS

5 days PTA 4 3 2 1 day PTA

Vertigo?
TEXT

HISTORY OF PRESENT ILLNESS

▸ Five days prior to admission, the patient experienced rotatory dizziness without any associated
symptoms such as headache, fever, vomiting, difficulty of breathing, chest pain and chest
heaviness.

▸ During the interim, patient experiences intermittent rotatory dizziness without associated
symptoms. She claimed that she was just experiencing vertigo since she was diagnosed with it
by an ENT physician. She also claimed that she missed 3 doses of Amlodipine. Every episode
of dizziness, she went to the center to check her BP. The results was 120/80 mmHg. No
medications was done. No consult was done.

▸ Few hours prior to admission, persistence of dizziness prompted consult at our emergency
room. Appropriate management was done but blood pressure was still noted to be elevated,
hence was advised admission, however patient opted to go home against medical advice. She
was sent home with medications and instructions.

▸ Few minutes prior to admission, dizziness recurred hence consult at our emergency room and
subsequent admission.
CASE PRESENTATION

PAST MEDICAL HISTORY

▸ Hypertensive (since 2000)

▸ Usual BP: 120/80 mmHg

▸ Highest BP: 200/140 mmHg

▸ On Losartan 50mg & Amlodipine 5mg tablet

maintenance (poorly compliant)

▸ (-) Allergy, Bronchial Asthma, Diabetes, Convulsion, TB,

Cancer
CASE PRESENTATION

FAMILY HISTORY

▸ Diabetes (paternal)

▸ Hypertension (both sides, siblings)

▸ Liver disease (paternal side)

▸ Stroke (maternal side)

▸ Heart problem (sibling)

▸ (-) Heart disease, cancer, thyroid disease, psychiatric illness

CASE PRESENTATION

GENOGRAM
CASE PRESENTATION

PERSONAL AND SOCIAL HISTORY

▸ Office worker

▸ 1 stick per day

▸ Occasional drinker (red wine)

▸ Caffeine

▸ Diet: Fatty and oily foods

CASE PRESENTATION

OB-GYNE HISTORY

▸ G3P3 (3003)

▸ All NSVD

▸ Menopaused for 4 years

▸ Pre-eclampsia (1995)
CASE PRESENTATION

REVIEW OF SYSTEMS
no presence of fever, weakness
General and easy fatiguability. No
weight loss

no rashes, discoloration, scaling,

Skin itchiness, dryness, redness, pain

presence of dizziness. No
Head nausea. No swelling,
lightheadedness

no discharge, diplopia, changes in

Eyes vision or excessive tearing

Nose no discharge, itching, pain, swelling,

epistaxis and stuffiness.
CASE PRESENTATION

REVIEW OF SYSTEMS
no chest pain, palpitations,
Cardiovascular orthopnea, no paroxysmal nocturnal
dyspnea

Pulmonary no orthopnea, no hemoptysis, no

dyspnea, no cough

no constipation, diarrhea, vomiting.

Gastrointestinal no anorexia, hematemesis,
hematochezia, melena, jaundice

no stiffness, no myalgia, no joint pain,

Muskuloskeletal no weakness, no limitations of
movement, no myalgia
CASE PRESENTATION

REVIEW OF SYSTEMS

Genitourinary no dysuria, no nocturia, no polyuria,

no hesitation, no urgency

Hematologic no anemia, no easy bruising, no

pallor

no constipation, diarrhea, vomiting.

Endocrine no anorexia, hematemesis,
hematochezia, melena, jaundice
CASE PRESENTATION

PATIENT IS ALERT, AWAKE, AMBULATORY AND COHERENT.

NO SIGNS OF CARDIORESPIRATORY DISTRESS AND PAIN WITH PROPER
POSTURE AND APPROPRIATE FACIAL EXPRESSION.
PATIENT IS MEDIUM BUILD, NO INVOLUNTARY ACTIONS, WITH NO
MALODOROUS SCENT NOTED.

General Survey
CASE PRESENTATION

PHYSICAL EXAM
VITAL SIGNS

Blood Pressure 160/100 mmHg

Heart Rate 89 bpm

Respiratory Rate 17 bpm

Temperature 36.0˚C

23.22 (NORMAL)
BMI wt: 115lbs ht: 4’11”
CASE PRESENTATION

PHYSICAL EXAM
✴ SKIN

▸ Brown, warm to touch, slightly elastic, mobile and capillary refill of

less than 2 seconds, pinkish nail beds with no clubbing noted, no
lesions, no tenderness, no masses

✴ HEENT

▸ Normocephalic head, no deformities, no tenderness, anicteric

sclerae, pinkish palpebral conjunctiva, no alar flaring, patent nasal
passages, midline septum, frontal and maxillary sinuses are non-
tender, no nasoaural discharge, moist lips and oral cavity, uvula at
midline and non hyperemic tonsils
CASE PRESENTATION

PHYSICAL EXAM
✴ NECK

▸ Supple neck, trachea is at the midline, with no mass noted, no neck vein
distention, no bruit on carotid artery, and no cervical lymphadenopathy

✴ CHEST AND LUNGS

▸ Symmetrical chest expansion, breathing is quiet and regular, no

retractions, no use of accessory muscles, resonant on percussion on all
lung fields, no adventitious lung sounds noted

✴ HEART

▸ Adynamic precordium, apex beat was noted on 6th ICS left, normal
cardiac rate, regular rhythm, no murmurs noted
CASE PRESENTATION

PHYSICAL EXAM

✴ ABDOMEN

▸ NOT ASSESSED
✴ EXTREMITIES

▸ NOT ASSESSED
CASE PRESENTATION

PHYSICAL EXAM
✴ NEUROLOGIC PHYSICAL EXAMINATION

▸ Awake, coherent, cooperative

▸ No aphasia

▸ Oriented to 3 spheres (place, time and person)

▸ Intact immediate, recent and remote memories

CASE PRESENTATION

PHYSICAL EXAM

✴ CRANIAL NERVES

▸ I - not assessed

▸ II - 2-3 mm, equally reactive to light

▸ III, IV, VI - Intact Extraocular Muscles

▸ V - Intact V1, V2 and V3 sensory distribution

▸ VII - Symmetrical face with equal sensation

CASE PRESENTATION

PHYSICAL EXAM

▸ VIII - Intact equal hearing

▸ IX, X - (+) gag reflex

▸ XII - midline tongue with no deviations; uvula is at the

midline

▸ No dysmetria, no dysdiadochokinesia, (-)Romberg's

▸ (-)Babinski sign

▸ Chaddock's sign, Brudzinski sign, Kernig's not assessed

CASE PRESENTATION

PHYSICAL EXAM

▸ 5/5 on upper and lower extremities

▸ Sensory: 100% on all extremities

CASE PRESENTATION

SALIENT FEATURES (HISTORY)

✓ 58 years old

✓ Dizziness

✓ Hypertensive

✓ Poor compliance to maintenance medications

✓ Family history

✓ Diet (Mostly fatty and oily foods)

✓ Caffeine
CASE PRESENTATION

SALIENT FEATURES (PHYSICAL EXAM)

✓ Increased blood pressure

✓ No neck vein distension

CASE PRESENTATION

DIFFERENTIAL DIAGNOSIS
DIZZINESS

OTOLOGICAL CARDIOVASCULAR OTHERS

VERTIGO UNCONTROLLED
HYPERTENSION

ACUTE CORONARY
SYNDROME

ISCHEMIC HEART DISEASE

CASE PRESENTATION

DIFFERENTIAL DIAGNOSIS
CASE PRESENTATION

CLINICAL IMPRESSION

HYPERTENSIVE
URGENCY
CASE PRESENTATION

AT THE EMERGENCY ROOM

S O A

VS: BP 160/100
RR 17
June 2, 2019
HR 89
2:57 PM O2Sat 98%
Temp 36˚C
Hypertensive
(+) dizziness
(-) fever
Urgency;
(-) vomiting Awake, alert, not in Benign Paroxysmal
(-) chest pain
cardiorespiratory distress Vertigo;
(-) chest heaviness
(-) DOB R/O Ischemic Heart Disease
CASE PRESENTATION

AT THE EMERGENCY ROOM

P

• 12-L ECG
• Betahistine 24mg/tab “now”
• Irbesartan 150mg/tab “now”
• Monitor BP every 15 mins
• Amlodipine 100mg
• Advised admission
CASE PRESENTATION

UPON ADMISSION
S O A

VS: BP 160/100
RR 17
June 3, 2019 HR 83
1:20 AM O2Sat 98%

(+) dizziness
Temp 36.5˚C
Hypertensive
(-) fever Urgency;
(-) vomiting Awake, alert, not in
(-) chest pain cardiorespiratory distress T/C Benign Paroxysmal
(-) chest heaviness Vertigo
(-) DOB
CASE PRESENTATION

UPON ADMISSION
P

• Monitor vital signs every 4 hours

• Diet: Low salt, low fat
• IV
• Labs:
‣ 12L ECG, Na, K, Creatine, CBC+Platelet Count, Hemoglucose Test, Chest Xray
• Meds:
1. Irbesartan 150mg/tab
2. Amlodipine 10mg/tab
3. KCl tablet
4. Omeprazole 40 mg/tab
5. Betahistine 16mg/tab
6.Nicardipine drip at 1mg/hour if systolic BP is ≥ 130
• Referred to IM-Cardio
• Vital signs, Input, Output were monitored
CASE PRESENTATION

FIRST HOSPITAL DAY

S O A P

VS: BP 110-120/80
RR 17
June 4, 2019 HR 89
7:10 AM O2Sat 98%
Temp 36˚C
Hypertensive
(-) dizziness Urgency;
(-) fever Awake, comfortable, • Discontinue
not in Benign Nicardipine drip
(-) vomiting • Fit for discharge
(-) chest pain cardiorespiratory Paroxysmal
(-) chest heaviness distress Vertigo;
(-) DOB
CASE PRESENTATION

DIAGNOSTIC EVALUATION

▸ CBC APC ▸ SGPT

▸ CREATININE ▸ URIC ACID
▸ SODIUM ▸ FBS
▸ POTASSIUM ▸ URINALYSIS
▸ HAEMOGLUCOTEST ▸ 12 LEAD ECG
▸ LIPID PROFILE ▸ CHEST XRAY
CASE PRESENTATION

DIAGNOSTIC EVALUATION
CBC APC
CASE PRESENTATION

DIAGNOSTIC EVALUATION
CREATININE, SODIUM, POTASSIUM
CASE PRESENTATION

DIAGNOSTIC EVALUATION
HEMOGLUCOTEST
CASE PRESENTATION

DIAGNOSTIC EVALUATION
LIPID PROFILE, FBS, URIC ACID
CASE PRESENTATION

DIAGNOSTIC EVALUATION
URINALYSIS
CASE PRESENTATION

DIAGNOSTIC EVALUATION
CHEST XRAY

✓ Consider possibility of slight cardiomegaly however,

magnification of cardiac shadow is possible due to poor
inspiratory effort. Suggest correlation with ECG findings
to confirm the presence of cardiomegaly. Atheromatous
Aorta.
CASE PRESENTATION

MANAGEMENT
A. NON- PHARMACOLOGIC
✓ Monitor your blood pressure at home.

✓ Weight loss for patients who are overweight or obese Heart-

healthy diet (such as DASH) Sodium restriction

✓ Potassium supplementation (preferably in dietary modi

cation)

✓ Increased physical activity with structured exercise program

✓ Limitation of alcohol to 1 (women) or 2 (men) standard

drinks per day
CASE PRESENTATION

MANAGEMENT
B. PHARMACOLOGIC
✓ Four classes of oral antihypertensive drugs are recommended
as first-line agents for the treatment of hypertension.

1.Thiazide or thiazide-type diuretics

2.Angiotensin-converting enzyme (ACE) inhibitors

3.Angiotensin receptor blockers (ARBs)

4.Calcium-channel blockers (dihydropyridines 


and nondihydropyridines) 

HYPERTENSION
(HIGH BLOOD PRESSURE)
CASE PRESENTATION

DEFINITION
‣ Blood pressure is the force of blood pushing against blood
vessel walls. It is measured in millimeters of mercury (mm Hg)

‣ High blood pressure means the pressure in your arteries is

higher than it should be

‣ sustained elevation of BP

‣ Systolic blood pressure ≥140 mm Hg

‣ Diastolic blood pressure ≥90 mm Hg

CASE PRESENTATION

American Heart Association

CASE PRESENTATION
CASE PRESENTATION
CASE PRESENTATION

HYPERTENSIVE CRISIS
EMERGENCY VS URGENCY
‣ Severe elevation
 ‣ Severe elevation of BP
of BP (greater than (greater than 180/120
180/120 mm Hg) mm Hg) in otherwise
associated with evidence stable patients without
of new or worsening acute or impending
target organ damage. change in target organ
damage or dysfunction
‣ BP must be immediately
reduced to prevent or
limit further damage.
CASE PRESENTATION