History and Physical Presentation for a Patient with Myocardial Infarction

History and Physical Presentation for a Patient with Myocardial Infarction

Case scenario

The case involves a male patient 65 years of age. His name is Mr. M.S. and presented to the cardiologist’s office in critical condition. He was fully conscious and well oriented. The chief complains were chest pains, breathlessness, and vomiting.

History of Presenting Illness

He first experienced chest pains 6 hours before presenting to the office. The pain had a sudden onset, located in the retrosternal region. The pain was radiating to the left arm, back, and neck. The pain he explains to be crushing in nature. The pain aggravated on exertion, and he felt some relief with rest while lying in the recovery position.

He also developed shortness of breath within the last 6 hours. It also had a sudden onset and was present even when the patient was at rest. He neither had a cough, wheezing, nor hemoptysis.

The patient also reported sudden vomiting, which started within 5 hours to presentation and had 3 episodes of emesis. The vomitus was yellow.

Past medical History

• Known diabetic for the past 12 years. Has been Glucophage 500 mg twice daily and glucomet once daily.
• He has had coronary artery disease and hypertension for the last 2 years on medication.
• He has neither known allergic reactions nor intolerance to medications.
• He was reported to have poor compliance with his treatment.

Past Surgical History: no known surgical history

Personal, social and economic History

• He is a chronic smoker, smoking a pack a day.
• He has no history of alcohol intake.
• He reports having a sedentary lifestyle.
• The patient is a retired government worker.
• He has private insurance.
• The patient lives with his son’s family, where his primary care provider is his daughter in law, and they live within the city.

Family History

• There is a history of hypertension and diabetes from his father and older brother.
• Two of his other brothers had died of myocardial infarction a few years ago.

Review of System (Subjective)

Eyes -Reports reduced vision due to aging.

Ears, Nose, Mouth, Throat- have no reported abnormalities.

Cardiovascular- Reports Having Experienced PALPITATIONS.

Respiratory: Difficulty in Breathing, Shortness of Breath, and Shallow Breathing.

Gastrointestinal:  He Reports To Have Nausea And Vomiting. He Has A reduced appetite.

Musculoskeletal:  body weakness and fatigue, sweating

Neurologic:  fully conscious and well oriented and dizziness.

Psychiatric: Disturbed sleep patterns.

Hematologic: no abnormalities.

Allergies:  he has no known allergies to medications or foods.

Vital Signs

Weight- 200 pounds

Height- 6’ 7”

Body Mass Index (BMI) – 31 kg/m²

B/P – 160/90 mmHg

Heart Rate- 115 b/min

Respiratory Rate- 30 breaths/ min

SPO₂ –  84 % on Room air

Pain Level-  9/10

Physical Examination

Eyes- No jaundice, No pallor

Ears- no discharge

Nose – no abnormalities

Mouth- good dental hygiene

Neck- no palpable swellings

Cardiovascular system- There is no chest deformity,

• -Apex beat is lateralized from the midclavicular line at the 6 th intercostal space because of LVH.
• -On auscultation S1 normal (apex) and S2 is audible (at the left sterna edge)
• No murmurs heard.

Respiratory system- the chest is clear; there is no tracheal shift and use of accessory muscles.

Gastrointestinal system: The liver and spleen are not palpable.

Genitourinary system: there are no remarkable abnormalities.  Urine is clear amber in color.

Skin: his skin is pale with Poor skin turgor, moderate fever

Neurologic System: He is conscious, the GCS at 15/15.

Differential diagnosis

The subject and objective data can provide preliminary information narrowing down to the three diagnoses listed below.

1. Myocardial Infarction
2. Unstable angina
3. Pulmonary Embolism

Myocardial infarction and unstable angina can be attributed to the chest pain that was radiating to the back. Pulmonary edema could be associated with chest pain and respiratory problems (Anderson & Morrow, 2017).

Diagnostic Testing

ECG showed that:

• Sinus rhythm
• Heart rate 78.9
• V1 TO V6 and AvL shows ST-segment elevation, Q wave development, loss of the R wave, and T wave inversion.

Cardiac biomarkers test:

• Troponin T 72 ng/L (H)
• CK- MB 36 IU/L (H)

Other blood tests

• ESR 28 mm/hr (H)
• CPR 7.0 mg/ L

Chest  X-ray: showed an increased cardiothoracic ratio due to L.V.  dilatation. Pulmonary edema was not evident.

The diagnosis from the diagnostic test was anterolateral ST-Segment Elevation Myocardial Infarction with Left Axis deviation. This is most notably from the ECG and the cardiac markers (Zafari & Abdou, 2020).

Management

The patient was started on oxygen 4L via face mask, and the SPO2 increased to 96%. The medications included:

• Chewable aspirin 325mg stat as it is an anti-platelet drug interfering with the clotting process.
• Due to the severe pain, he was given 4 mg of slow intravenous morphine.
• 10 mg of intravenous metoclopramide stat was given as an antiemetic.

The emergency medical services had been notified to help in the transfer of the patient. They were given the patient’s referral letter, which showed the diagnosis and the reason for referral. It also indicated the lab results, ECG and echocardiogram results, and the medications given to the patient.

Patient and family education included:

• Lifestyle changes to stop the sedentary life and teach on regular exercises.
• There is a need for dietary changes, including lowering cholesterol intake.
• They were taught that he needs to stop cigarette smoking.

The follow up for the patient included close follow up with the endocrinologist as well as the cardiologist.  During the visits, he showed improvement with blood pressure and sugars under control. During the routine visits, the ECG and echo showed remarkable improvement.

In retrospect, the patient was diagnosed early and managed well, preventing cardiac arrest. However, according to the guidelines, we were not able to start the patient on fibrinolytics.

References

Anderson, J. L., & Morrow, D. A. (2017). Acute Myocardial Infarction. New England Journal of Medicine, 376(21), 2053–2064. https://doi.org/10.1056/nejmra1606915

Tidy, D. C. (2016, May 12). Acute Myocardial Infarction, Myocardial infection. Patient. Retrieved on June 25, 2020, from patient.info website: https://patient.info/doctor/acute-myocardial-infarction#:~:text=Differential%20diagnosis&text=Cardiovascular%3A%20stable%20angina%2C%20another%20form

Zafari, A. M., & Abdou, M. H. (2020). Myocardial Infarction: Practice Essentials, Background, Definitions. EMedicine. Retrieved on June 25, 2020, from https://emedicine.medscape.com/article/155919

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