Question

Ms. X., aged 55 years, has been complaining of severe fatigue and “indigestion.” Her son is quite concerned and decides to take her to the emergency department. On arrival she appears very anxious, and her facial skin is cool and clammy; her blood pressure is 90/60, and the pulse is around 90, weak, and irregular. She is given oxygen, an intravenous line is opened, and leads for ECG are attached. Blood is taken for determination of serum enzymes and electrolytes. Tentative diagnosis is myocardial infarction involving the left ventricle. Her son provides information that indicates Ms. X is a long-time smoker, has a stressful job as a high school teacher, is recently separated after 20 years of marriage, and is fearful of losing the family home. She has also seemed to be more fatigued and stopped going to the gym about 18 months ago. She has begun to rely on “fast foods” like pizza and fried chicken and cooks infrequently. Her father had died of a heart attack at age 50. She had also noticed more fatigue and intermittent leg pain when walking or climbing stairs at work. Generalized atherosclerosis is suspected.

1. What is “atypical” in Ms. X’s symptoms? How does this affect treatment and prognosis?

2. What information do serum enzyme and electrolyte levels provide?

3. What purpose does the ECG serve? It is determined that Ms. X. has a large infarct in the anterior left ventricle.

4. Ms. X. is showing increasing PVCs on the ECG. State the cause and describe the effect if these continue to increase in frequency.

5. On day 6 after admission Ms. X is preparing to go home with her son and they receive instructions on lifestyle modifications that are desirable if Ms. X is to avoid another MI. What measures should be included in such a discussion?

Ms. X’s condition becomes less stable and she remains in the hospital. On the seventh day following admission, she is found unconscious on the floor of her bathroom. Her pulse is weak and elevated, and her skin is moist with pallor evident. Her BP is 50 systolic. A diagnosis of cardiogenic shock is made and resuscitation efforts are started.

6. Explain why Ms. X. has experienced cardiogenic shock at this time.

7. Describe the effects of cardiogenic shock on the organs of the body.

8. What problems will occur if decompensated shock occurs? How is compensation limited in this situation?

9. Ms. X dies shortly later. What is the cause of death in this case?

Answer 1

1. What is “atypical” in Ms. X’s symptoms? How does this affect treatment and prognosis?

Mrs X has pulse within the normal range. But her pulse is quite week and blood pressure is low,

Having though less blood pressure, the oxygen administration will bring a saturation in oxygen and helps to delivery it well to the tissues. Having pain in the legs is indicative that she has hardening of arteries, but these can be treated by using anticoagulant drugs.

2. What information do serum enzyme and electrolyte levels provide?

In case of diseases like myocardial infarction, the arteries get damaged because there is less blood supply and hence the tissues become necrosis. Hence certain enzymes as well as electrolytes are released into the blood and thus the inflammation starts. This increase in the enzymes indicate that there is a damage to arteries. Also electrolytes like sodium ,potassium are increased in the blood stream leading to damage to arteries. This elevated levels of enzymes and electrolytes helps in diagnosing the problem at the earliest.

3. What purpose does the ECG serve? It is determined that Ms. X. has a large infarct in the anterior left ventricle

Purpose of ECG:

• It helps to understand the rate at which the heart beats.
• It helps to make out the rhythm or the type of heart beat.
• It helps to determine if there is any heart related abnormality to the individual.

Here Mrs X has large infarct in the anterior left ventricle which causes increase in beats from the ventricular muscle cells.

4. Ms. X. is showing increasing PVCs on the ECG. State the cause and describe the effect if these continue to increase in frequency

PVC refers to Premature Ventricular Contractions.

Cause: Since there is a large infarct in the anterior left ventricle, it indicates that there is an increase in beats from the ventricular muscle cells and as a result the ventricles of the heart contract much before the atria is able to fill with blood.

Effect: If Premature Ventricular Contractions occur frequently, then ventricular fibrillation is developed.

5. On day 6 after admission Ms. X is preparing to go home with her son and they receive instructions on lifestyle modifications that are desirable if Ms. X is to avoid another MI. What measures should be included in such a discussion?

Instruction on lifestyle modifications are:

1. Avoid smoking
2. Avoid caffeinated drinks
3. Simple exercises can be advised, specifically encourage walking.
4. Avoid junk foods, avoid lot of fried items.
5. Include salads in her diet.
6. Provide diversional therapy like reading books, listening to music, make friends so that the patient feels stress free.
7. Practice early to bed and early to rise policy so that the early air causes much freshness to the patient.

6. Explain why Ms. X. has experienced cardiogenic shock at this time

Mrs X has got cardiogenic shock because her heart was not able to pump blood properly as the arteries where damaged. Also she has history of atherosclerosis, father being died of heart attack, was prone to eating lot of junk foods, hence she has suffered from this shock.

7. Describe the effects of cardiogenic shock on the organs of the body

Most of the body organs are affected. Since there is less supply of blood to the body, the nutrients required to the body is not enough for the organs to functions. Hence the respective organs try to work hard to compensate the loss leading to damage the organs.

8. What problems will occur if decompensated shock occurs? How is compensation limited in this situation?

As there is less blood supply, the cells cannot function normally. Hence it becomes difficult to reverse to original functioning as the cells and tissues die fast and not able to recover or compensate.

This leads to many complications in the body such as failure of certain body organs, overall multiorgan failure, coagulation problems etc.

9. Ms. X dies shortly later. What is the cause of death in this case?

The main cause of death of Mrs X was cardiogenic shock. The reason being,the heart not able to pump blood properly as there was the damage of arteries which lead to inability of body to reach out for nutrients.