ooOoo, im gonna get in so much trouble for this
usyd grad med/dent pbl working problem 1
TRIGGER TEXT Mr Sarich's chest pain
Image: Overweight, middle-aged man in emergency medicine clutching his chest while his wife mops his brow.
You are a medical student assigned to a registrar on duty in the Emergency Medicine Department at Central City Hospital. About 30 minutes before you see him, Mr John Sarich was wrapping and stacking newsapers at his suburban newsagency when, over the course of a few minutes, he felt a pain in his chest. He called his wife, who was working with him in the shop, and she drove him to hospital.
When you see him Mr Sarich says he is still in pain.
PATIENT DATA Mr Sarich's chest pain
Presenting Problem
John Sarich is a 55 year old newsagent who has been brought to the Emergency Dept by his wife with a half hour history of continuing chest pain.
History of the Present Illness
7 am today:
the patient was wrapping newspapers in his shop when he felt the sudden onset of chest pain.
chest pain - crushing, retrosternal, radiating to left arm and throat.
the patient felt anxious and called his wife. She decided to drive him to the nearby hospital emergency department because the GP wasn't open and she didn't want to wait for an ambulance.
three days ago Mr Sarich had a similar but milder central chest pain and discomfort in his left arm when carrying shopping parcels for his wife. Had to stop. Pain and discomfort disappeared within three minutes and he carried on. This was the first time he had ever experienced these symptoms.
two nights ago there was a further episode of chest pain and arm discomfort while watching television following a heavy meal. The pain was distressing and lasted a few minutes. He assumed he had indigestion.
On arrival in Emergency Department
still in severe chest pain - described as being "like a compressing steel band" around his chest. It did not vary with respiration and did not radiate through to the back.
Arm discomfort - described as a "vague heaviness".
Patient felt nauseated and slightly short of breath.
No recent history of fever, respiratory tract infection, blood-stained sputum or purulent sputum.
Initial Assessment
Overweight.
Distressed, pale, sweating slightly.
Pulse rate 90/min, respiratory rate 26/min.
Blood pressure 185/95.
JVP not elevated and no peripheral oedema.
Heart sounds soft, 4th heart sound audible.
Chest - a few scattered basal crepitations bilaterally
Initial Investigations
ECG : ST segment elevation in leads V1 to V4, consistent with acute anterior myocardial infarction. No evidence of old infarction
Initial Management
ECG monitor attached.
Oxygen administered via mask.
Intravenous cannula inserted and blood drawn for biochemistry and haematology.
Morphine 5mg given intravenously (for pain relief).
Rapid assessment of suitability for primary coronary angioplasty (balloon dilatation) performed, risks and benefits of angioplasty explained, and consent to perform angioplasty obtained.
Patient urgently transferred to the cardiac catheterisation laboratory. Angiography showed 90% narrowing of the left anterior descending (LAD) artery.
Successful angioplasty and stenting of the blockage in the LAD performed within 45 minutes of Mr Sarich arriving at the Emergency Department.
Rapid resolution of chest pain and ECG changes after angioplasty and stenting.
Patient transferred to the Coronary Care Unit.
Subsequent Detailed Assessment
Past History
No known major illnesses.
No previous hospitalisations, including no previous operations, visited doctors infrequently.
Specific vascular risk factors:
Smokes 20 cigarettes per day and has done so since age ~20 years.
High blood pressure (150/95) noted during an insurance examination 5 years ago. Subsequently confirmed by the GP on several occasions.
Total cholesterol 6 mmol/L documented by the GP several months ago. Had been instructed about a diet to lose weight and asked to come back for review, but did not return.
No known diabetes, but never checked.
No past history of gastrointestinal bleeding, no other major symptoms on systems review.
No medications.
No known allergies.
Personal History
Works as a newsagent. Normally has a very high physical workload, but in the last 12 months has had some additional financial problems which were adding emotional stress.
Lives at home with his wife and two children. Wife also has full time job.
The family eats out at least twice a week.
Does no regular exercise outside of work.
Alcohol: 1 - 2 glasses of beer every night.
Family History
The patient's father died of a myocardial infarction at the age of 70 (his first myocardial infarction having occurred at the age of 53).
Mother alive and well.
No known heart disease in 2 siblings.
Examination
Weight 100kg.
Height 185cm.
Pulse rate 70/minute and regular.
Blood pressure 150/90.
JVP 4cm above sternal (breastbone) angle. (Note: Physical examination of jugular venous pulse (JVP) is an integral part of cardiovascular examination and provides valuable information to reach diagnosis and monitor therapy for many cardiac illnesses. Clinicians often neglect this part of examination. During clinical teaching it should be emphasized that precise bedside analysis of jugular venous pulse and pressure is not only possible but also highly desirable. In healthy persons the JVP is 3-4cm above the sternal notch or angle)
Heart sounds soft, no murmurs, 4th heart sound no longer present.
Chest clear.
Pedal pulses normal, no peripheral oedema.
Soft bruit (bruit is an auscultatory sound) over the right carotid and the left femoral arteries.
No abnormality found on examination of other systems.
Other Investigations
ECG - ST segments have returned to baseline, but T waves inverted in leads V1-V6.
Full blood count from admission: normal.
Plasma biochemistry from admission: Glucose 8.8 mmol/L (normally fasting levels 4-6); otherwise normal.
Serial markers of myocardial injury:
Creatine kinase (CK), troponin T
Admission: 180, 0.1
+8 hours: 1600, 2.0
+24 hours: 640, 4.1
+72 hours: 210, 1.8
Lipid profile: Total cholesterol 5.3 mmol/L.
Chest X'ray: mild cardiomegaly, mild pulmonary venous congestion.
Echocardiogram showed reduced wall motion in the anterior wall of the left ventricle.
Diagnostic Decision/Mechanism
Blockage (thrombus) of a coronary vessel (artery) resulting in ischaemia, hypoxia and cell death within the myocardium.
Management
Urgent relief of the blockage (medical emergency), either by PTCA (Percutaneous Transluminal Coronary Angiography) and stenting or by the administration of thrombolytic therapy.
Subsequent Progress
Monitored in the Coronary Care Unit for 48 hours before transfer to a general ward.
No further chest pain, no heart rhythm disturbances or other complications.
BP monitored: 120/90
Blood glucose levels: normal
Discharged 5 days after admission.
Long-term Management
Discharged on drug therapy:
An anti-inflammatory drug with anti-clotting effects (Aspirin) 100mg daily (indefinite)
Anti-platelet drug (Clopidogrel) 75mg daily (6 weeks)
A beta-blocker with anti-hypertensive effects (Atenolol) 50mg daily (indefinite)
Angiotensin Converting Enzyme (ACE) inhibitor, anti-hypertensive and vasodilator for heart failure (Enalapril) 5mg daily (indefinite)
Cholesterol-lowering drug, that inhibits enzyme in liver (HMG-Co A reductase) e.g., Pravastatin 40mg daily (indefinite)
Patient referred to a cardiac rehabilitation program to provide further education, detailed dietary advice, commencement of a graded exercise regimen and support towards smoking cessation.
Advised to see his GP within the first week.
Advised to have his lipid levels checked in three months.
