ANSWERS ON QUESTIONS

Main part

Patient M. 56 years old, a seller of jewelry, was hospitalized on December 11 with

complaints of intense burning pain throughout the chest for 7.5 hours, with

radiating to the left shoulder, neck, lower jaw, elbow, also complained about

perspiration, palpitations, weakness, shortness of breath at rest, coughing.

Medical history. Height - 178 cm, weight - 105 kg. I do not smoke. Father at 49 years old

myocardial infarction. From the age of 35, the patient notes an increase in blood pressure to

180/100 mmHg Art. Examined, takes Perindopril 10 mg at night, metoprolol

succinate 100 mg in the morning. In 2011, she noted a condition characterized by loss

motor activity of the right upper limb for 3 hours, then spontaneously

motor function recovered. 13 year old female patient with diabetes 2

type, takes Metformin 1000 mg / day. Used by glucometer, blood sugar in

within 9.5 mmol / l. Since May, marks attacks of pressing pain behind the sternum with

physical activity (walking on flat terrain up to 600 meters) lasting

up to 5 minutes, which stopped after stopping walking. Treated on an outpatient basis and

stationary, diagnosed with ischemic heart disease, additionally

Acetylsalicylic acid 75 mg / day, rosuvastatin 10 mg / day,

short-range nitrates as needed. In August, scheduled

coronary angiography, isolated lesion of the anterior descending (PNA)

coronary artery - 95% stenosis in the middle third. In view of the severity of the lesion immediately

stent stenosis of the PNA with a drug-coated stent was performed. Patient

after discharge, it is recommended to continue taking therapy, including Aspirin,

Metoprolol succinate, perindopril, rosuvastatin and metformin, as well as during

one year of clopidogrel 75 mg / day. Two days before the present deterioration, the patient

stopped taking clopidogrel, justifying this with bleeding dѐsen.

Deterioration in the form of the appearance of intense pain in the chest

the cell at rest appeared at 06-00. The patient took 4 tablets on her own

Nitroglycerin without effect and at 12-00 after the appearance of shortness of breath and weakness, applied for

medical help.

I called an ambulance (SMP). When examined by a doctor

serious condition due to pain in the chest, shortness of breath, hypotension (BP -

100/60, heart rate - 98 per minute). An electrocardiogram (ECG) was recorded (see below). FROM

undecided pain syndrome delivered to the admission department.

Objectively: a serious condition due to pain in the chest,

shortness of breath, hypotension. On examination, the skin of marble, cold,

pronounced wet. Dyspnea persists at rest, breathing rate up to 28 per minute,

the patient takes an imposed half-sitting posture. Auscultatory over everyone

pulmonary fields moist finely bubbling rales. Pulse on the radial arteries

markedly weakened, filiform, 120 beats per minute. Auscultatory in the heart

I tone is weakened, tachycardia up to 120 per minute, systolic murmur is heard on

the top. Blood pressure on the right upper limb - 80/50 mm RT. Art., on

left upper limb - 75/50 mm RT. Art. There are no edemas on the lower extremities. ECG in

reception compartment without dynamics, compared with the SMP film.

Additional examination methods. General blood test: hemoglobin - 139 g / l,

white blood cells - 11 × 10 9 / l, erythrocytes - 4.8 × 10 12 / l, ESR - 8 mm / hour.

Biochemical blood test: sugar - 22 mmol / l, creatine kinase total fraction -

1900 U / l, creatine kinase-MV fraction - 102 U / l, troponin T - 2.9 ng / ml; common

cholesterol - 6.2 mmol / l, low-density lipoprotein cholesterol - 4.1 mmol / l; pH

blood - 7.2.

According to echocardiography, the ejection fraction of the left ventricle is 38%, expressed mitral

papillary dysfunction, mitral regurgitation III, myocardial hypertrophy

left ventricle. According to measurements of invasive hemodynamics, the central

venous pressure - 260 mm of water. Art. (N - 90-110 mm. Water. Art.).

Pressure jamming pulmonary capillaries - 23 mm RT. Art. (N - 10-18 mmHg)

Cardiac Index - 1.9 L / min / m 2

(N - 2.5-4.5 l / min / m

2

)

Saturation - 69% (N - 80-100).

X-ray in mild venous congestion of the III degree, the shadow of the heart is expanded

to the left.

ECG at the stage of the NSR.

Questions:

1. Highlight the syndromes, identify the leader.

2. Formulate a diagnosis.

3. Justify your diagnosis.

4. Make a plan for additional examinations.

5. Prescribe treatment.

Situational task 225 [K002908]