Transcript case history

DR. ZAHOOR
1

A 50 year old man presents to clinic with a
complaint of central chest discomfort of 2
weeks’ duration, occurring after walking for
more than 5 minutes or climbing more than 1
flight of stairs. The chest discomfort resolves
with rest within several minutes. He is obese,
has a history of hypertension, and smokes 10
cigarettes a day. His father died from a
myocardial infarction at the age of 54 years.
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On examination, his blood pressure is
144/92 mmHg with a heart rate of 82bpm.
The remainder of his examination is normal.
Questions
 What is the diagnosis?
 What two advise you will give to patient?
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•
A 60 year old man with a history of a
myocardial infarction presents to clinic for
follow up. He was started on aspirin, beta
blocker, and statin therapy after his heart
attack. In the past 2 weeks the patient has
noted return of chest pressure when he walks
rapidly. The chest pressures resolves with
sublingual glyceryl trinitrate or a decrease in
his activity level. He is a former smoker and
has modified his diet and activity to achieve
his goal body weight.
4
He is normotensive on examination with a
heart rate of 72 bpm. The remainder of his
examination is normal.
Questions
• What is the diagnosis?
• What first investigation you will do?
• If ECG is normal, what will be your next
investigation?
5

John is a 64 year old male new to the area
who presents to the surgery. John reports
that he has a history of hypertension (20
years) and angina (2 years). He was a heavy
smoker, 30 per day for 48 years, but ceased
9 months ago. He has no history of
gastrointestinal bleeding and nil known
allergies.
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A letter from his previous GP reports that
John has a non ST segment elevation
myocardial infarction (NSTEMI) 12 months
ago for which he underwent a percutaneous
transluminal coronary angioplasty and stent
to his left coronary artery. John was involved
in a cardiac rehabilitation program at the
local hospital for six weeks after his
discharge. Since then he walks briskly for 40
minutes every day and describes no angina.
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Current medications: aspirin 100mg daily,
clopidogrel (Iscover, Plavix) 75mg daily,
perindopril (Coversy) 4mg daily, simvastatin
(Lipex, Simar, Zocor) 20mg daily. Further
discussion identifies John’s lack of
understanding of the purpose of his
medicines and he admits to not always being
complaint.
8
On examination his blood pressure is
145/85mmHg, pulse rate 80 per minute
regular and his chest is clear on auscultation.
Echocardiogram six months ago showed no
evidence of heart failure. Body mass index is
23.5 kg/m2.
9
Blood results taken six weeks ago were
mostly normal but you note a total
cholesterol of 5.5 mmol/L, low density
lipoprotein (LDL) cholesterol 3.9 mmol/L,
high density lipoprotein (HDL) cholesterol 0.8
mmol/L and triglycerides 1.8mmol/L.
Questions
• What is acute coronary syndrome?
• Will you do exercise test in a patient with
NSTEMI?
10
•
A very physically active 49 year old male with a
history of labile hypertension and
hypercholesterolemia with an LDL cholesterol of
126 mg%. He underwent an exercise stress test
which revealed reversible inferoseptal ischemia at
a peak heart rate of 171 bpm and peak blood
pressure of 195/85. In the expert’s opinion, the
results suggest that the patient has silent
myocardial ischemia and may be at risk for
sudden cardiac death, especially in light of the
marked exertional level of activity.
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The expert suggests additional testing in order
to conform or exclude a coronary artery
obstruction, and to determine the right medical
therapy and/or intervention. In the meantime, he
suggests a reduction in physical activity.
Questions
• What is the diagnosis?
• What are the risk factors present in this patient?
• What will be your next investigation?
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