Summative Essay Assignment on Myocardial Infarction

Case Study : David Komber

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David is a 68 year old male who is a retired school teacher.He lives with his wife and son. He is normally fit & healthy. He has  regular walks and plays badminton weekly .  He complained of chest pain to his wife who called the ambulance. He was brought to the local ED with crushing central chest pain (feeling tight) and acute shortness of breath (SOB). He also felt palpitations. He has previous cardiac history. He was diagnosed with hypertension 25 years ago and hypercholesterolemia for which he takes regular medications. In the ambulance the ECG initially showed  tachycardia  with a heart rate of 145 beats per minute and ST elevation. ECG on admission suggested an anterior myocardial infarct [MI] confirmed by follow up ECGs.  He was sent to the catheter laboratory for a primary percutaneous coronary intervention (PCI).

Medications:

Amlodipine : 5 mg OD(once a day)

Lisinopril : 10 mg OD

Atorvastatin: 20 mg OD

On examination in ED , he was pale, clammy,

BP                    127/56;

Pulse                 133 beats per minute

Monitoring in Sinus Tachycardia

Temperature     36⁰ C

Respiratory Rate 35 breaths per minute

Oxygen Saturation : 84% on rebreathing bag.

Chest  auscultation : Wheezy

Initial blood results in ED

Hb      : 134 g/L

WCC: 5.8 X10⁹/L

Platelets      : 290 X10⁹/L

Glucose: 8.l mmol/l

Na: 139 mmol/l

K   : 4.5 mmol/l

Creatinine: 82 umol/L

Urea: 4.2 mmol/L

Creatine Kinase(CK): 890 U/L

Troponin T = 15 ng/mL

Total cholesterol: 7mmol/L

High Density Lipid(HDL): 1.8 mmol/L

Low Density Lipid (LD)L:  7 mmol/L

Triglycerides: 4 mmol/l

INR    : 1.3

APTT: 34 sec

ECG  showed a  LBBB.  With ST elevation in leads V1-V4..

The plan is to :

Cardiac monitoring via defibrillator pads

Cannulate  with large bore venflon.

Catheterise

Start   ACS protocol : administer Aspirin 300 mg & Clopidogrel 75 mg

intravenous infusion of GTN

To give analgesia and anti emetic :

Morphine 10 mg PRN

Metoclopramide 10 mg

Patient was started on high flow oxygen.

Initial Arterial blood gas showed :

pH 7.073 ;pCO2 :3.6 KPa; pO2 : 9 Kpa; HC03 :23.6 ;BE :8.5

Repeat ABG: pH :7.260 ;pCO2 :5.1 KPa ;pO2 :10.9 KPa ;HCO3: 20.8;

BE :6.4

Respiratory Rate of 36 bpm using accessory muscles.

BP 106/76; Pulse 122 beats per minute; Temp 36.9°C.

He was very anxious but settled a little since explanations given about his care.

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