Clinical Presentation

March, 2013

Myocardial Infarction

Universidad VeracruzanaFacultad de Medicina

The patient’s interview

He’s feeling a little better than he did this morning.

What happened this morning? To start at the beggining, he was going to his car All of a sudden he got a terrible pain in his chest It went down his left arm. After that he broke into a cold sweat. He became real nauseated. He had to lean against the car. He felt he might faint an minute. His wife saw this and came outside immediately.

Practice sentences

He told her what happened. She went inside and called the family doctor. The doctor sent an ambulance over for him. The doctor met him in the emergency room. Did the pain feel as though there was

something heavy pressing on his chest? Did the pain last for the entire period of time? Does he recall being short of breath? He honestly can’t remember. Has he ever had this happened before?

Practice sentences

Intern: Hello, Mr. Scott. I’m Dr. English.

Patient: Hello, Dr. English.

Intern: How are you feeling now?

Patient: Well, I’m feling a little better than I did this morning

Intern: What happened this morning?

Patient: Well, to start at the beginning, I was going to my car, when all of a sudden I got a terrible pain in my chest, which went down my left arm. After that I broke into a cold sweat and became real nauseated. I had to lean against the car, because I felt I might faint any minute. My wife saw this and came outside immediately. I told her what happened. She then went inside and called our family doctor. He sent an ambulance over for me and met me in the emergency room and, well… here I am.

I: Did the pain feel as though there was something heavy pressing on your chest?

P: Yes, it did.I: Did the pain last for the entire period of

time before you came to the hospital and were treated by yourprivate physician?

P: Yes, it did.I: Do you recall being short of breath?P: I honestly can’t remember.I: Have you ever had this happen before?P: No.

Has he ever had any heart trouble? Did he ever have rheumatic fever as a child? Did he ever had scarlet fever? I have his previous history here. He’s never been short of breath on exertion. He’s slept on one pillow all of his life. He’s never had swelling of the ankles. He’s never had toget up during the night to

pass his water. Is all that correct?

Practice sentences

Has he noiced any of these symptoms recently? Has he ever had any chest pain before? This is the first time. Is there any history of heart disease in his

family. His father died of a heart attack. So did his uncle. He says he felt light-headed. Is that right? He didn’t actually experience unconsciouness? I’ll be back in a few minutes, and we’ll esamine

him then.

Practice sentences

I: Have you ever had any heart trouble that you know about?

P: None.I: Did you ever had a rheumatic ot scarlet

fever as a child?P: No.I: I see here in your previous history that

you’ve never been short of breath on exertion, have slept on one pillow all of your life, never had swelling of the ankles, nor had to get up during the night to pass you water. Is that all correct?

P: Yes.

I: Have you noteced any of these symptoms recently?P: No, I haven’t.I: Have you ever had any chest pain before?P: No, this is the first timeI: Is there any history of heart disease in your family?P: Yes, my father died of a heart attack, and so did

my uncle.I: You said you felt light-headed. Is that right?P: Yes, it is.I: The you didn’t actually experienced

unconsciousness?P: That’s correct.I: I’ll be back in a few minutes, and we’ll examine

you then.

Conference with the physician (patient’s family doctor)

The patient is doing just fine, considering what he had.

What do you think he had? A myocardial infarction. I have to agree with that. Why don’t we go to the lounge and discuss

the problem? Then we can come back and see him again. What did you find on the physical exam? There really wasn’t anything remarkable.

Practice sentences

Does that surprise you? What conditionswould you think of in ruling out an

MI? I would think of pulmonary embolus and cardiac

neurosis. I would think of dissecting aneurysm and acute

pericarditis. I would also consider hiatal hernia. He wasn’t in shock when I saw him. Nor was there any evidence that he was going into

acutepulmonary edema. Would you expectto see fever at the onsetof his

condition?

Practice sentences

It’s usually absent at the onset. This is in contrast to acute pericarditis. It usually will risewithing 24 hours and

remain about a week.

Practice sentences

Physician: Hello, Dr. English. How’s Mr. Scott doing?

I: Just fine, considering what he had.Ph: What do you think he had?I: A myocardical infarction.Ph: I have to agree with that. Why don’t we go

to the lounge and discuss the problem? Then we can come back and see Mr. Scott again.

I: Fine.Ph: What did you find in the physical exam?I: There really wasn’t anything remarkable.Ph: Does that surprise you?I: No, not really.

Ph: What conditions would you think of in ruling out an MI?

I: Pulmonary embolus, cardiac neurosis, dissecting aneurysm, and acute pericarditis.

Ph: That’s quite good. I would also consider hiatal hernia. He wasn’t in shock when I saw him, nor was there any evidence that he was going into acute pulmonary edema. Would you expecto to see fever at the onset of this condition?

I: Yes, I would.Ph: It’s usually absent at the onset, in contrast

to acute pericarditis. It usually will rise within 24 hours and remain about a week.

Have an y of his lab studies come back? Yes, they’re over here. Well, his white count is normal. This will probably go up tomorrow. It will probably stay up for about a week. Willyou please order another one for tomorrow? What would you expect the sed rate to show? That also goes up about the second day It will remain elevated for more than a week. Which one of these will reamin elevated longer? Has the cardiogram come up to the floor? Has it come up with the rest of his chart?

Practice sentences

These waves look abnormal. His rate and rythm appear to be all right. What complications will you be looking for? What will you look for during his recovery period? I’ll look for congestive heart failure. I’ll look for pulmonary embolus. This would be secondry to phlebitis of the leg. I’ll look for arrhytmias and cerebrovascular

accident. I’ll look for rupture of the heart and shock. What are the most common arrhytmias during this

period?

Practice sentences

Ventricular premature beats are the most common.

Arterial fibrillation and prolonged A-V conduction are next.

Let’s see him for a few minutes now.

Practice sentences

Physician: Have any of his lab students come back?

Intern: Yes, they’re over there.Ph: Well, his white count is normal. This will

probably go up tomorrow and stay up for about a week. Will you please order another one for tomorrow? What would you expect to sed rate to show?

I: That also goes up about the second and will remain elevated for more than a week.

Ph: I see his SGOT is elevated, and so is the LDH. Which one of these will remain elevated longer?

I: The LDH.Ph: Has the cardiogram come up to the floor with

the rest of his chart.I: Yes it has. Here it is.

Ph: Here is elevation of the ST segment and T-wave. And these waves look abnormal. His rate and rythm appear to be all rigth. What complications will you be looking for during his recovery period?

I: Congestive heart failure; pulmonary embolus, secondary to phlebits or the leg; arrhytmias; cerebrovascular accident; rupture of the heart; and shock.

Ph: What are the most common arrhytmias during this period?

I: Ventricular premature beats are the most common. Atrial fibrilation and prolonged A-V conductions are next.

Ph: Let’s see him for a few minutes now.

“Let’s see him for a few minutes now”

He’s a little better than this morning. Has the chest pain decreased a little? Does he feel short of breath at all? Do his legs hurts? Lut’s unbutton his shirt for a minute. I want to listen to his heart. He should just lie still and let me do all the work Has his wife been into seehim yet. She’ll be here in about an hour. The doctor will be here, if he should feel any

shortness of breath.

Practice sentences

The doctor will be here, if he has a difficulty lying on one pillow.

Let the nurse know and she’ll tell the doctor about this.

Remember, it’s very important. Thank you for stopping by. I’ll see him tomorrow afternoon. Please, let me know if anything happens. He might go into failure, and you might not be

able to get me. If so, start treatment right away.

Practice sentences

Ph: Mr. Scott, how are you?P: A little better than this morning?Ph: Has the chest pain decreased a little?P:Yes, it has.Ph: Do you feel short of breath at all?P: No.Ph: Do your legs hurt when i do this?P: No, they don’t.Ph: Let’s unbutton your shirt for a minute so I can listen to

your heart… That’s fine. You just lie still and let me do all the work… Now take up a few deep breath… Fine… Has your wife been in to see you yet?

P: She’ll be here in about an hour.Ph: Fine. Dr. English will be here if you should feel any

shortness of breath or have difficulty lying on one pillow. Let the nurse know and she’ll tell Dr. English aboutthis. Remember, it’s very important.

P: I will certainly will, Doctor. Thank you for stoppping by.

Physician: Dr. English, please let me know if anything happens.

Intern: I certainly will.

Physician: If he should go into failure and you can´t get me, start treatment right away. See you tomorrow.

“What have you done for him?”

Sorry to wake you up. The patient has been very restless. He has great difficulty in catching his breath. He’s sitting up in bed now. Get the following things ready. Get an oxygen mask and 2cc. Mercuhydrin. Get 0.4 mg Cedilanid and a phlebotomy bottle. Get 500 mg of Aminophylline. Also see if you can get an ECG machine. We’ll have all those ready when you get here. I understand he’s having some difficulty.

Practice sentences

It was about an hour or so after he lay down. He has to sit up to catch his breath. He hasn’t been able to catch it at all. Just let me examine him for a few minutes. Have the bed propped up. I want the patient to sit upright. Put tourniquets on three extremities. Rotate them every fifteen minutes. Start the oxygen. Let me have the Cedilanid and the Mercuhydrin.

Practice sentences

This will make him feel more comfortable. We have the doctor on the phone. Do you want to talk to him now? I’m sure the nurse told you what has happpened. The patient has distention of his neck veins. He has persistant basilar rales. He has a gallop rythm. His liver is down one finger breadth. There is some slight sacral edema. He’s not into shock presently.

Practice sentences

Wht have you done for him? We’re using oxygen by face mask and

rotating tourniquets. We’re using Mercuhydrin 2cc. IM Cedilanid

2cc. IV The patient is in the upright position. I have a phlebotomy bottle here as well as

aminophylline. Thanks for calling, and I’ll be right down.

Practice sentences

Nurse: Dr. English, sorry to wake you up, but Mr. Scott has been very restless. He has great difficulty in catching his breath, and he´s sitting up in bed now.

Intern: All right, I´ll be right down. Get the following things ready: oxygen mask, 2 cc. Mercuhydrin, 0.4 mg. Cecilanid, a phlebotomy bottle, and 500 mg. Of Aminophylline. Also, see if you can get an ECG machine. And call Dr. Black.

Nurse: All right, Doctor. We´ll have those ready when you get there.

Intern: Hello, Mr. Scott. I understand you´re having some difficulty.

Patient: Yes. About an hour or so after I lay down, I had to sit up to catch my breath, and I haven´t been able to catch it at all.

I: Just let me examine you for a few minutes… Nurse, have the bed propped up. Iwant the patient to sit upright. Put tourniquets on three extremities and rotate them every fifteen minutes. Start the oxygen and let me have the Cedilanid and Mercuhydrin… This will make you feel more comfortable, Mr. Scott.

Nurse: We have Dr. Black on the phone, Dr. English. Do you want to talk to him now?

Intern: Yes, I’ll be right there… Hello, Dr. Black. I’m sure the nurse told you what has happened.

Attending: Yes, she did.I: Mr. Scott has distention of his neck veins,

persistent basilar rales, and a gallop rythm. His liver is down one finger’s breadth, and there is some slight sacral edema. He’s not in the shock presently.

A: What have you done for him?I: Oxygen by face mask, rotating tourniquets,

Mercuhydrin 2 cc. IM, and Cedilanid 2cc. IV. The patient is in the uprigth position. I have a phlebotomy bottle here as well as Aminophylline.

A: Fine. Thanks for calling, and I’ll be right down.