Mr. Jones, a 58-year-old sales executive has arrived in Washington DC for a conv
ID: 3481512 • Letter: M
Question
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.
Vital signs
Complete blood count
Cardiac enzymes
BP- 160/110 mmHg
Hemoglobin: 19 gm/dl
Troponin I: 0.030 (normal < 0.012)
HR- 97 bpm
Hematocrit : 60%
Creatine kinase: 120 U/L (normal 25-90 U/L)
Temperature- 98 F
Leucocytes: 5800 cells/mm3
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:
8
Because, Mr. Jones, was not compliant with his medication and life style changes, he ended up in heart failure.
8a
Which side of the heart has failed in MR. Jones? ( 1point)
8b
Name a signs and symptoms of left sided heart failure ( 1 point)
8c
Explain in detail the mechanism of development of pulmonary edema in this patient. How do diuretics help in his treatment? ( 3 points)
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)
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)
Vital signs
Complete blood count
Cardiac enzymes
BP- 160/110 mmHg
Hemoglobin: 19 gm/dl
Troponin I: 0.030 (normal < 0.012)
HR- 97 bpm
Hematocrit : 60%
Creatine kinase: 120 U/L (normal 25-90 U/L)
Temperature- 98 F
Leucocytes: 5800 cells/mm3
Platelets: 300,000 cells/mm3
Explanation / Answer
8a.left side heart failure.
8b. Signs and symptoms - failure of left side of heart leads to congestion of lungs leading to
fatigue(due to reduced oxygen concentration in blood)
Dyspnea(shortness of breath)
Orthopnea (difficulty in breathing while lying down flat)
Paroxysmal nocturnal Dyspnea (sudden attacks of breathlessness at night hours)
Cardiac wheezing
Cyanosis (in advance stages due to low oxygen levels)
Crackling on chest auscultation (due to pulmonary oedema, it's heard initially at the base of lungs then may spread to entire lung)
Apex beat(due to enlargement of heart)
8b . pulmonary edema is accumulation of fluid in the lungs. Left atrium of heart receives oxygenated blood from the lungs through pulmonary veins. During left sided heart failure, the blood in pulmonary vein gets backed up leading to increase in pressure in the vein that results in escape of fluid from the blood to the alveoli of the lungs. Fluid in the alveoli reduces the oxygen capacity of it thereby leading to various signs and symptoms.
Diuretics are preload reducers that reduces the fluid volume circulating thereby reduces the pressure caused by fluid going to the heart and lungs.
9a. Cardiogenic shock occurs when there is inadequate blood perfusion due to primary cardiac failure.
Signs and symptoms
-low urine output(oliguria)
-altered consciousness
-rapid, weak, threads pulse
-low Blood pressure
- cold, clam my, mottled skin(cutie marmorata)
-hyperventilation
-fatigue.
-distended jugular vein.
-cold extremities
9b.short term compensation:activation of sympathetic nervous system that leads to increase in heart rate, increases myocardial contraction, reduces urine output and increases blood pressure,peripheral vasoconstriction.All these compensatory mechanism actually worsens the patient's condition.
Renin angiotensin aldosterone system also compensates the low tissue perfusion to some extent.
Long term compensatory mechanism would be eccentric and concentric hypertrophy of non is chemical part of cardiac musculature.
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