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1. characteristic of chest pain - sharp, burning

2. radiation of chest pain - where its spread

3. SOCRATES - associated symptoms (vomiting)

4. past medical history - surgeries, allergic, taking suplement, previous chest pain episode

5. social history - daily activities, smoking habits, alcohol, drugs, lifestyle

6. family history - heart attack, hypertension, gastric

7. how long pain lasted - sudden/reduced onsets

8. physical exam - vital signs, chest tenderness, heart sounds (murmur), sign of heart failure, ankle swelling

9. diagnostic test - GIT (ph monitoring), cardiac test (ECG), respiratory test (chest x-ray)

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1. pensioner -> retired person

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1. encik ibrahim -> old male (prone to get heart disease), sex linked disease

2. 63 y/o pensioner -> immunoconmpromised, aging

3. chest pain -> most common symptoms heart disease, git causes - acid reflux causing irritation of chest, injury (muscles, ribs, lungs) - respiratory complication

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1. pectic ulcer

2. pneumonia

3. trauma

4. gerd

5. IHD

6. TB

7. pneumothorax

8. muscle strains

9. acute coronary syndrome

10. ARF

11. artherosclerosis

12. congestive heart disease

13. cardiac tamponade

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"pressing” in nature - sudden occur, character pain feel something in chest tight and pressure rather stabbing and burning

dyspnoea - short breath

diaphoresis -excess sweating

epigastric - abdominal region over stomach

inspiration - inhailing air

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1. Encik Ibrahim said he felt pain while he was gardening. - vigorous act underlying heart disease, heart beat harder, chest pain occured

2. pain lasted for 5 minutes and - suggest stable angina becuz few minutes less 10 min and occur exertion of stress and release by rest, contrast mi for 20 minute and persist

3. was "pressing” in nature- feel chest tight indicate cardiac ischemia, not enough o2, narrow coronary artery, cause by physical activity, might felt chest pain

4. radiated down his left arm and up to his jaw - pain spread, shared neural pathway left arm t1 to t5, low jaw cervical spinal c3 to c4

5. felt fatigue had no dyspnoea,

nausea, vomiting, diaphoresis or other associated

symptoms - pt fatigue by low o2 supply, diaphoresis, GI complication, low 02 transport anemia (reynold numb increase)

6. He said that it was the first time he had chest pain. - sudden physiological changes , increased physical demand, increase risk factor

7. The pain

was not aggravated by inspiration, movements or posture. - breath or move tak teruk, no injury

8. He had no history of trauma,- no fractures, no injury, focus internal causes heart problems

9. chronic cough- no severe on the lung , rule out respiratory irritary complication

10. , or any other recent illness - reduces viral like myocarditis and pericarditis

11. and had not been on any travels recently. - does not come from endemic areas that exposed to infection

12. He had no history of hypertension, diabetes mellitus or asthma. - might not inherited disease,

13. On further questioning, Encik Ibrahim said he never

experienced epigastric discomfort before or after meals. - not relate git system,

14. His bowel movements were regular, and stools were normal in colour and consistency. - show not relate git system, and no infection no diarrhoea

15. Past medical history

Both his father and uncle had died suddenly at about 50

years of age. His mother died at the age of 65 years from carcinoma of the colon. He was the only child. Neither parents had hypertension, diabetes mellitus, asthma or known heart disease. - young age, causes coronary artery that cause sudden cardiac, other is stroke (sudden death)

16. Medication history – nil. - healthy rule out side effect or adverse effect

17. Social history - did not consume alcohol. - no cardiac myopathy, no liver complication contribute to fluid retention and heart strain

18. He was a

smoker and smoked up to 20 cigarettes per day for the

past 40 years. - major compli blood vessel and lung, bv can thick and narrow bv cause form thrombus, cause occlusion and sudden death like uncle, relate to lung inhail toxic , cause COPD , increase colestrol level form plaque atherosclerosis,

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1. characteristic of chest pain - sharp, burning

2. radiation of chest pain - where its spread

3. SOCRATES - associated symptoms (vomiting)

4. past medical history - surgeries, allergic, taking suplement, previous chest pain episode

5. social history - daily activities, smoking habits, alcohol, drugs, lifestyle

6. family history - heart attack, hypertension, gastric

7. how long pain lasted - sudden/reduced onsets

8. physical exam - vital signs, chest tenderness, heart sounds (murmur), sign of heart failure, ankle swelling, palpate chest pain, identify abnormal sound, BMI, cvs examination ( ECG, echocardiogram), auscultation, exercise stress test, coronary angiography, JVD test, lipid profile, fasting blood sugar (artherosclerosis)

9. diagnostic test - GIT (ph monitoring), cardiac test (ECG), respiratory test (chest x-ray), blood test ( troponin), nutrition intake rule out anemia, no internal bleed, d dimer test (smoking )

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1. cyanosis - bluish appearence in skin colour and lips

2. arcus senilis -grey or white arch that appear around the cornea of eye

3. xanthelasma - yellow growth on or near the eyelid

4. carotid bruit - abnormal sound heard when ausculating the carotid artery

5. jugular venous pressure - pressure in the jugular vein that is used to test the function of the right heart

6. dual rhythm - simultaneous and independent occurence of rhythm

7. murmur - abnormal swishing by rapid blood flow to the heart

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1. Anxious and overweight - due to high hr almost to tachycardia, might be obese

2. He had nicotine-stained teeth - due to prolonged smoking (40 yrs)

3. He was afebrile - no fever, no infection or inflammation

4. Blood pressure – 120/80 mmHg, heart rate - 100

bpm, regular - normal

5. No ankle/ pedal oedema, no pallor or cyanosis - no swelling on his feet, no infection, rule out gout, normal BV, no anemia, enough circulating oxygen level

6. No arcus senilis and no xanthelasma - not indicative of high cholesterol (rule out hyperlipidemia)

Weight - 95kg, Height - 1.65 m - obese (34.9)

Respiratory system: Normal - rule out respiratory complications

CVS: No carotid bruit, jugular venous pressure (JVP) not

raised - no arterial or jugular vein blockage, right heart is functioning normal

No cardiomegaly

Dual rhythm and no murmur

Gastrointestinal system: Normal

Nervous system: Normal

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1. physical exam - vital signs, chest tenderness, sign of heart failure, exercise stress test, lipid profile, fasting blood sugar (artherosclerosis)

2. diagnostic test - cardiac test (ECG), blood test ( troponin), d dimer test (smoking )

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1) LDL - bad cholesterol (high level,risk for heart disease and stroke)

2)HDL - good cholesterol ( absorb in the blood and carry back to the liver , high can lower the risk for heart disease and stroke)

3) ALT - an enzyme found in the liver that help convert protein to energy

4) AST - enzyme found in the liver, heart and muscle that speed up certain chemical reactions

5) CKMB - enzyme found in heart ,brain and skeletal muscle which catalyse the reaction of creatine and ATP to phosphocreatine and ADP.

6) Troponin t - A protein that found in heart and skeletal muscle and release into bloodstream when the heart muscle is damage

7) Troponin1 - A protein released into bloodstream when heart muscle is damaged

8) Homocycteine - Sulfur containing amino acid produces during the metabolism of methionine

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1) normal haemoglobin level - no anaemia

2) total cholesterol is at high risk - increase the risk of coronary artery disease

3) LDL is at high risk - may lead to atherosclerosis, increase the risk of angina and stroke

4) HDL is low - high possibility for high cholesterol cause atherosclerosis plaque which can narrow the arteries

5) triglyceride is high - associated with insulin resistance, metabolic syndrome and atherosclerosis

6) fasting blood glucose is normal - no diabetes mellitus

7) ALT and AST normal - normal liver function so not affecting cholesterol metabolism or fat storage

8) CKMB, Troponin t and 1 - no evidence of MI,

9) homocysteine is normal - no additional risk of endothelial damage or thrombus formation

10) chest radiograph is normal - heart size is normal and no sign of heart failure

11) ECG normal - heart function normal

12) exercise stress test - heart not getting enough oxygen during physical activity

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LEARNING ISSUES CVS with suggested activities