Question Description
Mr. Jones, a 58-year-old sales executive has arrived in Washington DC for a convention. He decides to go out with his colleagues and has a heavy dinner. He wakes up in the middle of the night with a dull ache in the center of his chest. He initially thinks, it is indigestion from the heavy meal that he had, but the chest pain gets worse and now starts radiating to the left shoulder, left jaw and left arm. He remembers seeing on TV, that what he is experiencing could be symptoms of a Myocardial infarction (heart attack). He immediately calls 911.
Once, the ambulance arrives, the EMT notices that Mr. Jones is sweating profusely and he is pale. The EMT immediately gives Mr. Jones, Aspirin, puts a oxygen mask and starts IV normal saline. If needed, other drugs can be given via the IV access.
As soon as Mr. Jones is brought to the Hospital, the ER nurse takes the vital signs and a brief history. An EKG is done and shows abnormalities, suggesting a MI. Blood is drawn to look for cardiac enzymes. Blood results are back and show elevated Troponin and Creatine Kinase, confirming that Mr. Jones is having a MI. His past medical history is significant for poorly controlled essential hypertension, poorly controlled Diabetes mellitus, Poorly controlled Hypercholesterolemia. His family history is unremarkable. He is a current smoker, has smoked 2 packs of cigarettes for the last 25 years and drinks beer on the weekends.
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Vital signs |
Complete blood count |
Cardiac enzymes |
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BP- 160/110 mmHg |
Hemoglobin: 19 gm/dl |
Troponin I: 0.030 (normal < 0.012) |
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HR- 97 bpm |
Hematocrit : 60% |
Creatine kinase: 120 U/L (normal 25-90 U/L) |
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Temperature- 98 F |
Leucocytes: 5800 cells/mm3 |
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Platelets: 300,000 cells/mm3 |
Jones is immediately taken to the operating room to do an Angiogram (procedure to visualize his coronary blood vessels) The doctors find a block in one of the major blood vessels and decide to do a angioplasty (minor surgery done to open blocked arteries).
After the Angioplasty, the, EKG comes back to normal and his cardiac enzymes are trending down. So, the physician decides to observe him in the hospital for 2 days. He is discharged on 3rd day, with advice to make life style changes and start medications: Aspirin, Metoprolol (Beta blocker), Simvastatin (for his high cholesterol) and follow up with his physician in his home town.
Mr. Jones was not compliant with his medications, made no changes to his life style. 3 months later, he visits his physician and complains of easy fatiguability, headaches, shortness of breath, unable to lie flat on the bed at night. He says that he has to sit up propped up against 4 pillows in order to sleep. On Auscultation of the chest, there are bilateral crackles heard. The physician concludes that Mr. Jones is in heart failure. He now prescribes Diuretics for Mr. Jones.
Questions:
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1a |
What are the normal values for PH, Erythrocyte count, Leucocyte count, Platelet count. ( 1 point each) |
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1b |
What are the terms used for increase and decrease in PH? ( 1 point each) |
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1c |
What are the terms used for Increase and decrease in Erythrocyte, Leucocyte, Platelet count? ( 1 point each) |
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2a |
From the complete blood count reading, what can you infer about the hemoglobin and hematocrit? ( high/ Low) ( 1 point) |
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2b |
From the history of the patient, explain along with the mechanism, why Mr. Jones has abnormal hemoglobin and hematocrit? ( 2 points) |
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3a |
In the ambulance, why did the EMT give oxygen as soon as he suspected that Mr. Jones could be having a myocardial infarction? ( 1.5 point) |
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3b |
What is the mechanism of action of Aspirin that is advantageous in Myocardial infarction? ( 1.5 points) |
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4a |
Does giving isotonic saline change the osmolarity of Mr. Joness blood? Why/Why not? ( 1 point) |
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4b |
What is the effect of istonic saline on the intravascular compartment and intracellular compartment? Explain ( 1 point) |
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4c |
In this patient, what cardiac enzymes were elevated? Explain why troponin level is elevated in a Myocardial infarction? ( 1 point) |
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5 |
Mr. Joness EKG shows electrical abnormalities. |
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5a |
In a normal EKG, what are the different waves, intervals, segments that you expect to see? ( 1 point) |
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5b |
What does each wave represent?( 1 point) |
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5c |
What is the significance of PR interval?( 1 point) |
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6a |
What are coronary arteries? What are the branches of right and left coronary arteries? (1 point) |
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6b |
If the angiogram showed a embolus in the left anterior interventricular artery, which part of the heart would be effected? ( 1 point) |
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6c |
If the ventricle of the heart is damaged, in which wave/ waves of the EKG will you see changes.( 1 point) |
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7 |
As a result of the Myocardial infarction and death of the effected cardiac muscle, |
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7a |
What happens to the stroke volume of the ventricle and why? ( 1 point) |
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7b |
As a result of the change in stroke volume, what happens to the cardiac output and total peripheral resistance (R) ( 1 point) |
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7c |
Why is giving a Beta blocker advantageous in Myocardial infarction ( 1 point) |
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8 |
Because, Mr. Jones, was not compliant with his medication and life style changes, he ended up in heart failure. |
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8a |
Which side of the heart has failed in MR. Jones? ( 1point) |
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8b |
Name a signs and symptoms of left sided heart failure ( 1 point) |
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8c |
Explain in detail the mechanism of development of pulmonary edema in this patient. How do diuretics help in his treatment? ( 3 points) |
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9a |
If the person is refractory to the heart failure medications, he can go into shock. What is the type of shock that you can expect in this person. What are some of the signs and symptoms of Shock? ( 1 point) |
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9b |
Explain in detail the short term and Long term compensatory mechanisms that come into play as a result of the condition in question 9a.( 2 points) Guidelines
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