Case 3

Case 3. Cardialgia (Infarction of myocardium)

Author: Victoria Khilchevska

Case outline

You are a young physician-therapist at the city clinic, leading an urgent reception of patients. A 47-year-old man, Alexander, appealed to you with complaints of pain in the epigastric area, right hypochondrium, nausea, heartburn, shortness of breath. I felt bad in the morning at work while working for a computer. Alexander works as a web-programmer in a large computer corporation who is not married, which explains a rigid inflammatory character and a reluctance to maintain long-term relationships. On the eve of her husband informed about the contraction at work, all evening he felt anxiety, depressed mood, sleep badly at night, in the morning he ate a lot and with appetite. Earlier, such symptoms were not observed, in the history - chronic noncalculous cholecystocholangitis. From bad habits - smoking for 10 years to 10-12 cigarettes per day. Alcohol does not abuse. Power is irregular, often uses fast food.

Over the past 2 years, it has noticed an increase in weight by 20 kg. Over the past 5 years, the patient registered high blood pressure (up to 160/95 mm Hg), antihypertensive drugs were taken irregularly. Arterial pressure in normal conditions 130/80 mm Hg.

In an objective examination, the patient's condition is closer to moderate severity. Consciousness is clear. Temperature 37.0С. When viewed slightly excited, the skin is clean, pale, but clinically not anemic. Visible mucous membranes of pale pink color, subcurrent sclera. Thyroid gland is not enlarged. Peripheral lymph nodes are not palpable. No peripheral edema.

Choices are denoted Excellent (E) / Good (G) / Poor (P)

Choice 1. Assign antisecretory, anti-emetic, antispasmodic remedy and release home (P). Refer for consultation to a gastroenterologist (G). Continue patient examination and examination (E).

While you were analyzing the blood parameters, the patient complained of an increase in pain in the upper abdomen, nausea, sour taste in the mouth, unpleasant sensations in the area of ​​the heart. The man looks pale, there is sweating, anxiety, a slight shortness of breath at rest. AT - 115/75 mmHg, heart rate 60 beats / min, WB 22 / min, capillary filling 2 s, SaO2 96%. He explains his anxiety to the unresolved problems at work. You offer Alexander hospitalization in the gastroenterological department for a more detailed examination, but he categorically refuses and requests you to prescribe him treatment for pain in the stomach and to let go home.

Choice 2. Perform an chest X-ray, ECG (G), repeated determination of troponin levels in blood after 4-6 hours and studying the level of KFK, KFK-MB, LDH (E), direction to the ultrasound of the abdominal cavity and EGDFS (P)

Choice 3. Urgent tactics of thrombolysis (E), carrying out a coronary artery with the decision on the issue of revascularization of the myocardium (G), conducting Echo-Cardiography with Determination of Ejection Fraction (P).

Learning outcome for VP case:

  • Leading clinical symptoms and syndromes myocardial infarction.
  • Differential diagnosis of infarction of myocardium and previous clinical diagnosis. Laboratory and instrumental datas of myocardial infarction.
  • Clinical management of patient
  •  Treatment and emergency for complications of myocardial infarction
  •  Preventing complications.

Medical error

  • Ignorance,
  • poor triage,
  • poor communication