PBL MYOCARDIAL INFARCTION
Trigger
Mr. Hafiz, 57 year old retired Manager, has a history of type II diabetes Mellitus for 7 years and hypertension for 15 years. He is a life long smoker. Mr Hafiz presented to the Emergency Room with 2 hours history of severe central chest pain accompanied by syncope.
On admission he is alert and conscious but in obvious distress.
You are the House Officer on-call. Outline your management plan on this patient.
History of Present Illness
Mr. Hafiz is a 57 year old ex-Manager of a hotel. He has 7 year history of Diabetes, and long standing hypertension. He attends the Endocrinology Clinic for his Diabetes. He has been completely well up to 4pm today when he suddenly developed increasing chest pain while gardening. His pain is described as constricting, located at the centre of the chest, radiating to his neck. He noticed sweating and nausea. While on his way by ambulance to the hospital, he felt breathless and obtained mild relief from the oxygen.
Past Medical History
Diabetes Mellitus – 7 years
Hypertension – 15 years
No surgical history
Family history
Father died suddenly at 55, also diabetic. All other family members well. Has 3 brothers and 2 sisters, all well. He is the eldest in the family.
Social History
Smoker – 20 cigarettes a day for 40 years
Does not drink
Retired Manager, doing light work at home. Lives with his wife.
Physical Examination
Alert and conscious but in pain. He looks pale, no jaundice or cyanosis. No pedal oedema. He has normal temperature, BP 135/85, pulse rate 100 per minute, Respiratory rate 20 per minute.
Cardiovascular system:
He has bilateral corneal arcus and xanthelasma on his left eye.
The JVP is normal. Heart sounds 1st and 2nd heard as well as 3rd (gallop). There is no murmur or other added sounds.
Respiratory examination
Normal chest expansion. Equal air entry with moderate bilateral fine crepitation at both lung bases
Abdominal examination
Soft, non tender abdomen with no organomegaly.
Nervous System
Full GCS. Normal tone, power, reflexes and sensation symmetrically.
Investigation:
ECG
CXR
FBC
Biochemistry
ABG
Urinalysis: glucose 2+
ECG later
Coronary Angiography
Creatine Kinase 258 U/L (24 - 204)
Troponin-T 0.06 ug/L (0 – 0.1)
Renal Profile
Sodium 136 mmol/L (135 - 150)
Potassium 3.5 mmol/L (3.5 - 5.0)
+ Urea 21.2 mmol/L (2.5 - 6.4)
+ Creatinine 155 umol/L (62 - 106)
Liver Function Test
- Albumin 30 g/L (35 - 50)
- Total Protein 64 g/L (67 - 88)
+ Bilirubin Total 75 umol/L < 23
+++ ALT 1691 U/L ( < 44)
ALP 86 U/L (32 - 104)
+ Creatine Kinase 321 U/L (24 - 204)
White Cell Count 12.6 x10^9/L (4.0 - 10.0)
Red Cell Count 4.65 x10^12/L (4.5 - 6.3)
Hemoglobin 14.4 g/dL (14.0 - 17.0)
Hematocrit 41.8 % (39.0 - 52.0)
Mean Cell Volume 89.8 fl (77.0 - 91.0)
MCH 30.8 pg (26.0 - 32.0)
MCHC 34.3 g/dL (32.0 - 36.0)
RDW 13.1 % (11.3 - 14.6)
Mean Platelet Volume 8.5 fl (6.3 - 10.2)
Platelet 212 x10^9/L (150 - 400)
Fasting Serum Lipid
Triglycerides 1.7 mmol/L < 1.40
Total Cholesterol 5.9 mmol/L <5.0
- HDL-Cholesterol 0.85 mmol/L >1.20
LDL-Cholesterol 3.8 mmol/L <3.0
Fasting Glucose 5.1 mmol/L (3.0 - 6.7)
ABG
+ pH 7.32 (7.35 - 7.45)
- pCO2 32.0 mmHg (35 - 45)
+ Std Bicarbonate 23 mmol/L (22 - 26)
Base Excess 1.7 mmol/L (-3 - +3)
+ pO2 80 mmHg (65 - 100)
+ O2 Saturated 98.0 % (90 - 96)
The patient was given oxygen, morphine, GTN and Aspirin 300mg. He was immediately thrombolysed with tPA and the ECG showed some resolution of the ST segment elevation. He was transferred to the Coronary care unit.
One hour after arrival he developed weakness and sweating. The monitor showed Ventricular Tachycardia. 100mg IV lignocaine was administered with immediate resolution. He was continued on heparin, aspirin, metoprolol and clopidogrel.
The following day coronary angiogram performed. This showed severe mid Right coronary artery stenosis and severe stenosis of the left main stem. Left ventriculography showed good left ventricular ejection fraction with no evidence of mitral regurgitation.
He was stable in the CCU. Echocardiography confirmed good left ventricular function with hypokinetic inferior wall. He was referred to the Cardiothoracic Surgeon for coronary artery bypass surgery.
