"myocardial infarction"

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"Myocardial infarction" Fisiopatología. Dr. Víctor Laura Cabrera Valencia

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  • 1.Universidad Veracruzana Facultad de MedicinaClinical PresentationMarch, 2013

2. Hes 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. 3. 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 cant remember. Has he ever had this happened before? 4. Intern: Hello, Mr. Scott. Im Dr. English. Patient: Hello, Dr. English. Intern: How are you feeling now? Patient: Well, Im feling a little better than I did this morning Intern: What happened this morning? 5. 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. 6. 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 cant remember. I: Have you ever had this happen before? P: No. 7. 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. Hes never been short of breath on exertion. Hes slept on one pillow all of his life. Hes never had swelling of the ankles. Hes never had toget up during the night to pass his water. Is all that correct? 8. 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 didnt actually experience unconsciouness? Ill be back in a few minutes, and well esamine him then. 9. 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 youve 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. 10. I: Have you noteced any of these symptoms recently? P: No, I havent. I: Have you ever had any chest pain before? P: No, this is the first time I: 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 didnt actually experienced unconsciousness? P: Thats correct. I: Ill be back in a few minutes, and well examine you then. 11. 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 dont 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 wasnt anything remarkable. 12. 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 wasnt 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? 13. Its usually absent at the onset. This is in contrast to acute pericarditis. It usually will risewithing 24 hours and remain about a week. 14. Physician: Hello, Dr. English. Hows 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 dont 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 wasnt anything remarkable. Ph: Does that surprise you? I: No, not really. 15. Ph: What conditions would you think of in ruling out an MI? I: Pulmonary embolus, cardiac neurosis, dissecting aneurysm, and acute pericarditis. Ph: Thats quite good. I would also consider hiatal hernia. He wasnt 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: Its usually absent at the onset, in contrast to acute pericarditis. It usually will rise within 24 hours and remain about a week. 16. Have an y of his lab studies come back? Yes, theyre 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? 17. 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? Ill look for congestive heart failure. Ill look for pulmonary embolus. This would be secondry to phlebitis of the leg. Ill look for arrhytmias and cerebrovascular accident. Ill look for rupture of the heart and shock. What are the most common arrhytmias during this period? 18. Ventricular premature beats are the most common. Arterial fibrillation and prolonged A-V conduction are next. Lets see him for a few minutes now. 19. Physician: Have any of his lab students come back? Intern: Yes, theyre 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. 20. 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: Lets see him for a few minutes now. 21. Hes 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? Luts 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. Shell be here in about an hour. The doctor will be here, if he should feel any shortness of breath. 22. The doctor will be here, if he has a difficulty lying on one pillow. Let the nurse know and shell tell the doctor about this. Remember, its very important. Thank you for stopping by. Ill 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. 23. 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 dont. Ph: Lets unbutton your shirt for a minute so I can listen to your heart Thats 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: Shell 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 shell tell Dr. English aboutthis. Remember, its very important. P: I will certainly will, Doctor. Thank you for stoppping by. 24. Physician: Dr. English, please let me know if anything happens.Intern: I certainly will. Physician: If he should go into failure and you cant get me, start treatment right away. See you tomorrow. 25. Sorry to wake you up. The patient has been very restless. He has great difficulty in catching his breath. Hes 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. Well have all those ready when you get here. I understand hes having some difficulty. 26. It was about an hour or so after he lay down. He has to sit up to catch his breath. He hasnt 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