Issuu on Google+

Ministry of health of Ukraine

Lugansk State Medical University Chair of internal medicine No. 1

Chief of department: Professor V.I. Kolomiyets Lecturer: Thereshenko

CASE HISTORY

Patients name: Lubkin Victar Fedorovich

Preliminary diagnosis: Acute Myocardial Infarction of anterior wall and apex - on 22 nd October 2010

Final diagnosis:


ISCHEMIC

HEART

DISEASE;

ACUTE

MYOCARDIAL

INFARCTION

with

Pathological Q wave; DIFFUSE INFARCTION OF ANTERIOR WALL, LEFT VENTRICLE; MYOCARDIAL NECROSIS Essential Hypertension II degree

Complications: POST INFARCTION CARDIOSCLEROSIS OF ANTERIOR WALL

Heart insufficiency II A stage

Concomitant disease: Diabetes Mellitus

Curator:

Kuboja Nyaruga 4th course Group no. 30

PASSPORT

Name of the patient:

Lubkin Victar Fedorovich

Sex:

Male

Nationality:

Ukranian

Age:

68 years

Date of birth:

29th February 1940

Height:

176 cm

Weight:

86 kg

Address:

kortara 28/6 2-22 dom


Occupation:

Had worked as a cashier till retirement, after which he had worked as

a laborer in many places

Date of admission:

Basic complains:

23rd December 2010

General weakness, compression feeling in chest, retrosternal pain radiating

to left arm

Preliminary Diagnosis:

Ischemic Heart Disease; Acute Myocardial Infarction; anterior

wall and apex on 22 October 2010 nd

Final Diagnosis: ISCHEMIC

HEART

DISEASE;

ACUTE

MYOCARDIAL

INFARCTION

with

Pathological Q wave; DIFFUSE INFARCTION OF ANTERIOR WALL, LEFT VENTRICLE; MYOCARDIAL NECROSIS Essential Hypertension II degree

Accompanying disease:

Diabetes Mellitus

Date of discharge:

stil hospitalised

COMPLAINTS OF THE PATIENT


At the time of curation, patient was active, he only had complaints of mild breathlesness, and dry cough.

ANAMNESIS MORBI On 22nd October patient felt an acute moderate pain in the chest, the pain radiated to his left arm. Since about 2 days prior to the pain attack patient had been having general weakness and a compression feeling in the chest. On 22 nd October (after the pain attack) patient went to polyclinic, which had refered him to the regional hospital. Patient came to hospital on 23rd of Octoberr, during which he had tachycardia (110 beat/min) and his blood pressure was 160/90. On the same visit he was hospitalised.

ANAMNESIS VITAE Patient did not have any significant disease during his childhood except for one episode of pneumonia attack, which was treated and he fully recovered. As a child he gained normal physical and mental development. He’s never suffered from any venereal disease like syphilis, gonorrhea, or any other chronic disease like tuberculosis or viral hepatitis. He has not undergone any surgical procedure. Patient had smoked for 50 years. He is to have Arterial Hypertension since 1970 (presently usual BP at around 160/90). And 3 years ago he was diagnosed with Diabetes type 2 (presently he’s on Glibenclamide 5mg - 2times/day)

He was hospitalized in the year 2000 with the complaints of pain in the region of heart and difficulty breathing, as then he was diagnosed for Ischemic Heart Disease Left ventricular Myocardial Infarction. After treatment he was well and working till he was admitted for DM in 2005. After that he again started working and on 23 October 2010 he was admitted due to severe retrosternal pain and chest compression. In the family Anamnesis he only remembers about his mother she died due to hemorrhage of the Brain. (Insult). He was the only one child in his family and he has one son , lives with his wife.


Patient is married, wife alive and has one son. Allergic Anamnesis: - Not known to be allergic to any drug or else.

PRESENT CONDITION OF THE PATIENT General inspection General condition of the patient was good. He was actively conscious. According to his age he had normal appearance, with adequate behavior. He has a cheerful nature, and had a straight line bearing, usual gait. Patient was 176cm tall, and weighed 86kg. Body temperature: 37 0 C. He had an normosthenic body constitution. Temperature charts show normal body temperature variations without any fever. Patients’ skin was abit pale, no sign of pigmentation or rashes. Skin was of normal humidity with normal elasticity and turgor. Mucous membrane of the eye was pink, jaundice not present, and had normal lacrimation. Mucous membrane of the nose was clean, covered by normal nasal hair. Mouth was considerably clean,pink mucous, without any pigmentation, ulceration or scaring. Scalp of the patient was clean. Coverred by normal humid hair,

loss of hair was not

prominent. Nails are seen as normal and healthy. patient has normal adequate fat tissue,bit more fat deposition on the abdomen. Patient had good muscular development, and normal skin. Muscular strenght was adequate, according to age and gender. No pain on palpation. Patient has a bending posture, can be seen moderate kyphosis at the thoracix vertebrae region. But no pain upon touch on either back bone, or other joints. Joints had no swellings, change in temperatue, or fluctuation. All joints had full active movement.

Respiratory System At the time of examination patient hadnoisy breathing and complained of slight dyspneo and cough. No hemoptysis. Patient had an normosthenic constitution. There is moderate kyphosis at the thoracix vertebrae region . No visible deformity in thoracix region.Unpronouced biletaral supra cavicular fossae. Intercostal intervals areequally spaced. Slight prominent scapular, but in normal position


and

symmetric

on both

sides, normal movement rhythmic and corresponds to respiratory

movement. Dynamic respiratory movements of the thorax was even and symmetric on both sides. Patient had abdominal breathing, of rhymthic breath of normal dept. Respiratory rate of the patient was 24 breaths per minute. No pain during palpation of the ribs, intercostals intervals and scapular. Elasticity of the chest is normal, with no abnormal rigidity of the chest. Vocal fremitus was equally pronounced from both sides. No sense of pleural friction. No presence of subcutaneous emphysema. Comparative percussion revealed clear sound, symmetrical on both sides.

Data of topographical percussion of the lungs

Height of apices of the lungs

On the right

On the left

In front

2 cm above clavicle

2 cm above clavicle

Behind

At the level of 7 th cervical vertebra

At the level of 7th cervical vertebra

Width of area of Krenig

3 cm

3 cm

Lower border of the lungs


Topographical lines

On the right

On the left

Parasternal

5th rib

-

Midclavicular

6th rib

-

Anterior Axillary

7th rib

7th rib

Mid Axillary

8th rib

8th rib

Posterior Axillary

9th rib

9th rib

Scapular

10th rib

10th rib

Paravertebra

11th thoracic vertebra

11th vertebra

Respiratory mobility of the lower border of the lung

thoracic


Mobility of the lower border of the lungs

Topographical lines

Mid Axillary

Right Lung

Left Lung

Inhalation

Exhalation

Total

Inhalations

Exhalation

Total

12th costal

8th costal

4cm

12th costal

8th costal

4cm

Auscultation of lungs revealed decreased vesicular breathing sounds, but clear and symmetrical on field of each lung and on both lungs. No additional respiratory

noises (such as

rales, crepitation or pleural friction) were heard during the auscultsation.

Cardiovascular System On inspection, no anomaly in the heart area was noticed. No cardiac hump. The apex beat was not visible. No swelling of cervical veins, venous pulse is negative. Normal positive pulsations felt at carotid, radial and femoral arteries. Epigastric pulsation is absent. Apex beat was palpated very faintly, at in the 5th intercostals space, at the left midclavicular line. Character of beat was positive and limited; it was weak and very low amplitude. No systolic or diastolic thrill. Character of peripheral pulse was determined at the radial artery; it was symmetrical, rhythmic, positive, 60 per minutes, very weak and of low filling and tension. He had an arterial pressure of 130/80; patient has history of secondary hypertension.

Percussion of the heart Place of determination

Relative dullness

Absolute dullness


Right

1 cm lateral to right edge of sternum

Left edge of sternum

Left

2 cm lateral clavicular line

At the mid clavicular line

Upper

3rd intercostals space

of

left

Width of the vascular bundle was 6cm.

mid

4th rib

Heart has Aortal configuration.

Transverse length of the relative cardiac dullness was about 18cm, showing cardiac enlargement.

Auscultation was difficult as the patient had weak heart sounds at all points. During the examination his heart beat was rhythmic, at 60 beats per minute

Consecutive auscultation was done by classical method as following:  At the Mitral valve (at the apex of the heart, on 5 th intercostals space, of left midclavicular line); 1st sound prevailed but both heart sounds were diminished. Slight systolic murmur was heard  Aortic valve

– (on the 2nd intercostals space on the right border of

auscultatry sounds were very faint with prevalence of 2

nd

the sternum) ;

sound

 Pulmonary valve – (on the 2 nd intercostals space on the left border of sternum) ; auscultatry sounds were very faint with prevalence of 2nd sound  Tricuspid valve – (at the junction between xyphoid process and the sternum) ; 1st sound prevailed but both heart sounds weaker than at mitral point  Botkin point – (on the 3rd intercostals space of left edge of the sternum); both heart sounds weak with non prevailing

Blood pressure:

Digestive system

5th February - 120/70;

pulse – 75 per minute

21st February – 130/80;

pulse – 60 per minute

22nd February – 140/90;

pulse – 60 per minute


Patient has good appetite. He had no complainsts of excessive thirst. Ordinary taste in the mouth. No pain inthe throat and no difficulty in swallowing or during passage of food. He had no complaint of pain, eructation or regurgitation, nausea, vomiting or hiccups. No complaints of constipation or diarrhea

Inspection of oral cavity: Mucosa color was pink, no pigmentation, rashes and no ulcer or hemorrhages. Smell of mouth is normal. Odor of the oral cavity was good. No anomaly of the gum. The teeth are normal. The tongue was clean and light pink in color. Condition of papillae is normal. No impressions of teeth on edges of tongue.

Inspection of abdomen: Abdomen was symmetrical on static, slight associated movement with respiration. No visible peristaltic movement or varicose veins at the abdominal wall. No visible herniation. There is a post operative scar, at the right iliac region after left after appendectomy.

Superficial and deep palpation of abdominal organs did not cause any pain to the patient and did not reveal any pathological signs.

On percussion of the liver showed normal sizes, with no enlargement of liver: 1st size (on right mid clavicular line) -

10.5 cm,

2nd size

(on the anterior mid line) -

9 cm

3rd size

(along the left costal arch) -

8cm.

Urinary System

Patient had no complaints of any pain in the lower abdomen or in the pelvic region. No pain during or after passing of urine. Patient has a normal frequency passing of urine which was of normal colour.


Inspection of the area of the kidneys shows no swelling or hyperemia. The skin over the lumbar area was pale pink in color without any rashes. Palpation of kidney area revealed mild pain, no pain at palpation of the upper and lower urethral painful points. Bimanual palpation of the kidney revealed no sign of nephroptosis. Both kidneys are present and located in normal positions. The Pasternatsky’s symptom is negative.

Endocrince System

Patient does not feel excessive thirst. Daily intake of fluid is about 2.5 litres, with normal unrination. No noticable edema. No changes in skin pigmentation or in body part size. No complains of changes in sensitivity.

THYROID GLAND No visible enlargment of the thyroid gland. On palpation thyroid gland was felt 1cm from either side of the trachea, no pain during normal swallowing or during examination. No external signs of thyroid anormaly, such as; exophthalmia, Graefe’s MOebius’, Stellwag’s, Kocher’s, tremor of the fingers. Skin was not dry, of ormal temperature, without any pigmentation.

No pathological signs suggesting disorders of HYPOTHALAMUS and PITIUTARY GLAND, PARATHYROID GLAND, ADRENAL GLAND, or SEXUAL GLANDS was revealed.

Sense Organs and Psychological Status Patient had no complaints of changed sensitivity, of touch, pain, vibration or tactile. He has normal sense of vision and hearing.


Patient is in clear consciousness and very active. He has good memory. No disorder in sleep.No complaints of headache, dizziness, nausea or vomiting. No noise in the ear, and has normal balance status of the body.

Nervous System The patient has a quiet mood. Has an active status and a good memory. He sleeps well and there is no complain of night mares or insomnia. The reaction of the pupil to light is simultaneously alive. The swallow reflex is normal. Superficial skin reflex, profound skin reflex and the Achilles tendon reflex are normal. No pathological reflexes. Patient has normal sensitivity, normal senses such as visionand hearing.

PRELIMINARY DIAGNOSIS

Preliminary diagnosis was based mainly in accordance to the basic complaints of the patient and findings during the examination,

Preliminary diagnosis:

ISCHEMIC HEART DISEASE; Acute Myocardial Infarction of

anterior wall and apex on 22nd December 2008

PLAN OF ADDITIONAL EXAMINATION 1. General Blood Analysis 2. Biochemical analysis of Blood 3. Blood Sugar Level 4. Coagulogram 5. Urine Analysis 6. X ray investigation of chest 7. Electrocardiogram


LABORATORY INVESTIGATIONS Blood tests:

Hb Erythrocytes Colour index Leucocytes Stabs Neutrophiles Segmented Neutrophiles Eosinophiles Lymphocytes Monocytes ESR

23rd December 2008 160 g/L 4.38 * 1012 /L 1.09 5.1 * 109 /L 3% 79% 0% 13% 5% 16mm/hr

27th December 2008 154 g/L 4.68 * 1012 /L 0.95 5.8 * 109 /L

23mm/hr

normals 120 – 140g/L 3.9 – 4.7 * 1012/L 0.8 – 1.0 4.0 – 9.0 * 109/L 1 – 5% 40 – 60% 1 – 5% 20 – 40% 2 – 10% 1 – 10 mm/hr

Biochemical test;

Direct Bilirubin Urea Creatinin Pottasium (K+) Sodium (Na+) ASAT ALAT Beta lipoprotein

24th December 2008 20 micromol/L 7.7mg/dL 8.8mg/dL 3.85mEq/L 135mEq/L 0.33 mmol/l 0.33 mmol/l 5%

27th December 2008

normals 3.33 – 8.33 mmol/L 0.05 – 0.11 mmol/L

3.85 133 0.33 mmol/l 0.33 mmol/l

0.1 – 0.64mmol/(h.ml) 0.1 – 0.68mmol/(h.ml)


Blood glucose levels

23rd December 2008 (3pm) 9.3 mmol/L

24th December 2008 (6am) 6.2 mmol/L (12pm)

8.3 mmol/L

(4pm)

8.5mmol/L

Patient’s sugar level continues to stay higher and is not controled being controled

Urine analysis:

23rd December 2008

Amount:

60ml

Colour:

yellow

pH:

acidic

Specific gravity:

1005

Protiens:

Nil

Leukocytes:

0–2

Erythrocytes:

1–2

Coaglugram

Prothrombin index:

95%

Prothroombin time:

22”

Tolerence for heparin: Fibrinogen:

8’ 40” 4%

X-ray result

Urine analysis is normal


X-ray shows increased heart borders towards left, and increased vascularisation in the lungs. Conclusion can be made as: Hypertrophy of left Ventricle; left heart failure causing venous retension in the pulmonary circulation.

ECG result ECG done on 23rd december 2008, right after hospitalisation shows: Heart rate: 111 beats/min - Sinus Tachycardia P wave: 0.1secs (normal is 0.08 – 0.12secs) PQ interval: 0.16secs (normal is 0.12 – 0.2secs) QRS complex: 0.02secs (normal is 0.06 – 0.1secs) – weak ventricular contraction T wave: 0.14secs (normal is 0.12 – 0.16secs) Ecg investigation also revealed: Pathological Q wave in leads V1 – V4 R waves in lead I, II, AVF, V5 and V6

SUGGESTED FURTHER STUDIES

Blood report of troponin, myoglobulin level, c-reative protein, ESR, level of LDH and HDH

Echo cardiography to check the condition of the walls and septa, functioning of atrium and ventricles, and presence of thrombus incavity of the heart.

Angiography by Coronary catheterization

SUBSTANCIATION OF CLINICAL DIAGNOSIS


The examinational point outs for the assumption preliminary diagnosis, together with laboratory results and instrumental investigations results and reveal of the ECG s’ taken during the hospitalization;

X-ray shows: Hypertrophy of left Ventricle; left heart failure causing venous retension in the pulmonary circulation.

ECG done on 23rd december 2008: Heart rate: 111 beats/min - Sinus Tachycardia QRS complex: 0.02secs (normal is 0.06 – 0.1secs) – weak ventricular contraction

Pathological Q wave in leads V1 – V4 R waves in lead I, II, AVF, V5 and V6

We can come to the final diagnosis of:

ISCHEMIC HEART DISEASE; ACUTE MYOCARDIAL INFARCTION with Pathological Q wave; DIFFUSE INFARCTION OF ANTERIOR WALL, LEFT VENTRICLE; MYOCARDIAL NECROSIS

Accompanying disease:

Complications:

Diabetes Mellitus

POST INFARCTION CARDIOSCLEROSIS OF ANTERIOR WALL

Heart insufficiency II A stage


COMPLEX TREATMENT REQIURED FOR MYOCARDIAL INFARTION GENERAL MEASURES Cardiac care unit monitoring should be instituted as soon as possible. Patients without complications can be transferred to a telemetry unit after 24–48 hours. Low-flow oxygen therapy (2–4 L/min) should be given if oxygen saturation is reduced. To prevent straining at stool and maintenance of normal bowel function give laxatives. Continued pain maybe relieved by7 administration of nitroglycerine, initially sublingually followed by continuous IV drip if needed. During initial days of hospitalization patient can be on catheterized urination. Activity should initially be limited to bed rest but can be advanced within 24 hours. Progressive ambulation should be started after 24–72 hours if tolerated. For patients without complications, discharge by day 4 appears to be appropriate.

ANTIPLATELET THERAPY Patients with definite or suspected myocardial infarction should receive aspirin at a dose of 162 mg or 325 mg at once regardless of whether thrombolytic therapy is being considered or the patient has been taking aspirin. Chewable aspirin provides more rapid blood levels. Patients with a definite aspirin allergy should be treated with clopidogrel; a 300 mg loading dose will result in faster onset of action than the standard 75 mg dose.

THROMBOLYTIC THERAPY Thrombolytic therapy is very important in the first few minutes and hours after onset of MI. It reduces mortality and limits infarct size in patients with acute myocardial infarction associated with ST segment elevation •

Streptokinase is not commonly used for treatment of acute myocardial infarction since it is less effective at opening occuluded arteries and less effective at reducing mortality. It is non-fibrin-specific, causes depletion of circulating fibrinogen.

Alteplase is a naturally occurring plasminogen activator that is modestly fibrin specific, resulting in about a 50% reduction in circulating fibrinogen.

ANTICOAGULANET THERAPY


After completion of the thrombolytic infusion, aspirin should be continued. Anticoagulation with intravenous heparin (initial dose of 60 units/kg bolus to a maximum of 4000 units, followed by an infusion of 12 units/kg/min to a maximum of 1000 units, then adjusted to maintain an activated partial thromboplastin time [aPTT] of 50–75 seconds beginning with an aPTT drawn 3 hours after thrombolytic) is continued for at least 24 hours after alteplase, reteplase, or tenecteplase but is optional in patients receiving streptokinase. With tenecteplase, enoxaparin, a 30 mg intravenous bolus, followed by 1 mg/kg every 12 hours, resulted in a lower incidence of the composite of death, myocardial infarction, refractory ischemia, and disabling stroke, but bleeding rates appear to be increased in the elderly. For all patients with acute myocardial infarction treated with intensive antithrombotic therapy, prophylactic treatment with antacids and an H 2-blocker is advisable. β-ADRENERGIC BLOCKING AGENTS Although trials have shown modest short-term benefit from intravenous β-blockers, such as atenolol, given immediately after acute myocardial infarction, it has not been clear that this provides a major advantage over simply beginning an oral β-blocker. The Chinese COMMIT/CCS-2 trial involving 45,000 patients found no overall benefit to intravenous followed by oral metoprolol; the aggressive dosing (three 5 mg intravenous boluses followed by 200 mg/d orally) appeared to prevent reinfarction at the cost of increasing shock in patients presenting with heart failure. Thus, β-blockade should be avoided in patients with decompensated heart failure, decompensated asthma, or high degrees of AV block.

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ACE inhibitor therapy by the use of drugs such as Captopril, Enalapril, Ramipril, benefits greatest, to patients with low ejection fractions, large infarctions, or clinical evidence of heart failure. Because substantial amounts of the survival benefit occur on the first day, ACE inhibitor treatment should be commenced early in patients without hypotension, especially patients with large or anterior myocardial infarction.

ANGIOTENSIN RECEPTOR BLOCKERS Although there has been inconsistency in the effects of different angiotensin receptor blockers (ARBs) on mortality for patients post-myocardial infarction with heart failure and/or LV dysfunction, the VALIANT trial showed that valsartan 160 mg twice a day is equivalent to captopril in reducing mortality. Thus, valsartan should be used for all patients with ACE inhibitor intolerance, and is a reasonable, albeit more expensive, alternative to captopril. The combination of captopril and valsartan (at reduced dose) was no better than either agent alone and resulted in more side effects.

ANALGESIA


An initial attempt should be made to relieve pain with sublingual nitroglycerin. However, if no response occurs after two or three tablets, intravenous opioids provide the most rapid and effective analgesia and may also reduce pulmonary congestion. Morphine sulfate, 4–8 mg, or meperidine, 50–75 mg, should be given. Subsequent small doses can be given every 15 minutes until pain abates.

CALCIUM CHANNEL BLOCKERS Calcium channel blockers such as Amlodipine, niphedipine, verapamil acts by relaxing the smooth muscle in the arterial wall, decreasing peripheral resistance and hence reducing blood pressure; in angina it increases blood flow to the heart muscle. Long-acting calcium channel blockers should generally be reserved for management of hypertension or ischemia as secondor third-line drugs after β-blockers and nitrates.

DIET THERAPY Diet of low calory and saturated fat, low salt is usualy recommended.

TREATMENT AND RECOMMENDATION FOR THE PATIENT UPON DISCHARGE:

Diet of low calory and saturated fat, low salt, and low protien. Tab. Amlodipine

5mg – 1 times daily

Tab. Vastarel (trimetazidin) Tab. Pravastati

35mg – once a week

10mg – 1 times daily before bedtime

Caps. Papaverin hydrochloridi Tab. Pentoxyphyllini

150mg – 2 time daily

0.1– 1 times daily

Tab. Famotidine

0.02 – 2 times daily

Tab. Silibori

0.04 - 2 times daily

Tab. Metoprolol

0.05 - 2 times daily

Tab. Pyridoxi hydro chloridi

0.01 - 1 times daily

Nitroglycerine spray - 0.4mg / dose Sol. Fraxiparine 0.3 mL - subcutaneously 1 times daily


Not to do heavy exercise. Recommended to come for review afer a month.


case history(therapy) (1)