Question

Mrs. Paula Johnson is a 65-year-old white woman with a previous history of a sedentary lifestyle, hypertension, hypercholesterolemia, and diabetes mellitus type II. She is a heavy smoker since she was 20 years old. She was brought to the emergency room because her family found her unresponsive on the floor. She was diaphoretic. Her family thought she had her diabetes decompensated. Mrs. Johnson’s daughter indicated her mother was complaining of nausea and epigastric pain the day before. Also, her blood pressure was high.

On the physical we found:

Remarkable Signs on Physical by Regions

• Chest: Palpitation

Remarkable Signs on Physical by Systems

• Integumentary system: Profuse diaphoresis, coldness, and pallor
• Respiratory system: Tachypnea
• Cardiovascular system: Weak pulse, tachycardia, and hypotension
• Nervous system: Unconsciousness. No other neurologic signs.

Lab Tests

• Complete blood count (CBC)
• Cardiac enzymes
• Glucose level
• Lipid panel
• EKG
• Cardiac catheterization

Diagnosis

• Silent myocardial infarction

Other Diagnoses

• Essential hypertension
• Dyslipidemia
• Diabetes mellitus

In at least 375 words, or 1.5 double-spaced pages, prepare a case report that addresses the following:

1. Based on the case study provided, respond to the following questions:
   • Mention the symptoms and signs you found in this patient.
   • Did you find any remarkable detail in the personal and social history of our patient that can help to make the diagnosis?
   • What is a silent myocardial infarction, and why did it happen to this patient?
   • What results do you expect to find in the tests ordered?
   • What are some differential diagnoses?
   • What are some complications of myocardial infarction?
2. The patient suffers from silent myocardial infarction, but there are other types of heart diseases. Consider these questions:
   • Describe the heart valvular disorders and how they can produce cardiac failure.
   • What is endocarditis, and what are the most common causes?
   • How many types of shocks are there? Explain them.
3. As a lifetime smoker, the patient is at risk of several respiratory disorders. Consider these questions:
   • What is COPD? What are the three most common diseases that produce a COPD? What are their causes?
   • What is asthma? Explain the origin of its symptoms.
   • What is a pneumothorax? What are its symptoms and signs, and what are its causes?

Answer 1

A)

1. Mention the symptoms and signs you found in this patient.

Ans) symptoms: nausea and epigastric pain

  Remarkable Signs on Physical by Regions

• Chest: Palpitation

Remarkable Signs on Physical by Systems

• Respiratory system: Tachypnea
• Cardiovascular system: Weak pulse, tachycardia, and hypotension
• Nervous system: Unconsciousness. No other neurologic signs.
• Integumentary system: Profuse diaphoresis, coldness, and pallor

2. Did you find any remarkable detail in the personal and social history of our patient that can help to make the diagnosis?

Ans) sedentary lifestyle and She is a heavy smoker since she was 20 years old

3) What is a silent myocardial infarction, and why did it happen to this patient?

Ans) Silent myocardial ischemia is defined as the presence of objective evidence of myocardial ischemia in the absence of chest discomfort or another anginal equivalent symptom (eg, dyspnea, nausea, diaphoresis, etc).

Silent myocardial infarction (SMI) relates to absence of symptoms usually associated with myocardial ischemia. Its risk factors include heavy smoking, family history of heart disease, age, high blood cholesterol and systemic blood pressure, diabetes, and overweight

4) What results do you expect to find in the tests ordered?

Ans)

Lipid Profie

lipid profile of the patients within the first 24 hours of the myocardial infarction was noted. On an isolated level, the most commonly deranged parameter was serum TGs - 70% had elevated TGs, followed by 32% patients who had elevated TC, 31.2% who had decreased HDL-C, and 28% who had elevated LDL-C.

Cardiac Enzyme

Myocardial muscle creatine kinase (CK-MB) is found mainly in the heart. CK-MB levels increase within 3-12 hours of onset of chest pain, reach peak values within 24 hours, and return to baseline after 48-72 hours. Sensitivity and specificity are not as high as for troponin levels.

EKG

In the first hours and days after the onset of a myocardial infarction, several changes can be observed on the EKG. First, large peaked T waves, then ST elevation, then negative T waves and finally pathologic Q waves develop.

5) What are some differential diagnoses?

Ans) Cardiovascular: stable angina, another form of ACS (unstable angina or NSTEMI), acute pericarditis, myocarditis, aortic stenosis, aortic dissection, pulmonary embolism.
Respiratory: pneumonia, pneumothorax.

6) What are some complications of myocardial infarction?

Ans)

• Cardiogenic shock: One of the life-threatening complications of STEMI is cardiogenic shock during which hypotension is present from low cardiac output.
• Left ventricular aneurysm: A left ventricular aneurysm can form after a STEMI.

B) The patient suffers from silent myocardial infarction, but there are other types of heart diseases. Consider these questions:

1) Describe the heart valvular disorders and how they can produce cardiac failure.

Ans) In valvular heart disease, the valves become too narrow and hardened (stenotic) toopen fully, or are unable to close completely (incompetent). A stenotic valve forces blood to back up in the adjacent heart chamber, while an incompetent valve allows blood to leak back into the chamber it previously exited.

This occurs when a heart valve doesn't fully open due to stiff or fused leaflets. The narrowed opening may make the heart work very hard to pump blood through it. This can lead to heart failure and other symptoms

2) What is endocarditis, and what are the most common causes?

Ans) Endocarditis is an infection of the endocardium, which is the inner lining of your heart chambers and heart valves.

Endocarditis is caused by bacteria in the bloodstream multiplying and spreading across the inner lining of your heart (endocardium).

3) How many types of shocks are there? Explain them.

Ans)

• Cardiogenic shock (due to heart problems)
• Hypovolemic shock (caused by too little blood volume)
• Anaphylactic shock (caused by allergic reaction)
• Septic shock (due to infections)
• Neurogenic shock (caused by damage to the nervous system)

C) As a lifetime smoker, the patient is at risk of several respiratory disorders. Consider these questions:

1) What is COPD? What are the three most common diseases that produce a COPD? What are their causes?

Ans) Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used, but are now included within the COPD diagnosis.

emphysema and chronic bronchitis are most common disease that produce a COPD

causes:
Smoking is the main cause of COPD and is thought to be responsible for around 9 in every 10 cases. The harmful chemicals in smoke can damage the lining of the lungs and airways. Stopping smoking can help prevent COPD from getting worse.

2) What is asthma? Explain the origin of its symptoms.

Ans) asthma is chronic disorder of the conducting airways usually caused by an immunological reaction, which is marked by episodic bronchoconstriction due to increase airway sensitivity to a variety of stimuli , inflammation of the bronchial wall, and increased mucus secretion

Symptoms: Recurring episodes of wheezing,

coughing,

chest tightness,

shortness of breath

3) What is a pneumothorax? What are its symptoms and signs, and what are its causes?   
Ans) A pneumothorax is a collapsed lung. A pneumothorax occurs when air leaks into the space between your lung and chest wall. This air pushes on the outside of your lung and makes it collapse. Pneumothorax can be a complete lung collapse or a collapse of only a portion of the lung.

Symptoms and sign:

• shortness of breath.
• chest pain, which may be more severe on one side of the chest.
• sharp pain when inhaling.
• pressure in the chest that gets worse over time.
• blue discoloration of the skin or lips.
• increased heart rate.
• rapid breathing.