Case Based Learning Pharmacology HSS 3101. Learning Objectives To understand the anatomical,...
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Case Based Learning Pharmacology HSS 3101. Learning Objectives To understand the anatomical, physiological, and pathological processes involved in cardiac
Learning Objectives To understand the anatomical,
physiological, and pathological processes involved in cardiac
emergencies. To understand the pharmacological and alternative
treatment options available for cardiac emergencies. To become
familiar with the first aid approach involved in cardiac
emergencies. To understand the social factors involved in the
pathogenesis of various cardiac disorders that consequently result
in cardiac emergencies.
Slide 3
Case Introduction A 53 year old man, Mr. David Smith, suddenly
started having chest pain. His wife called the ambulance, and
paramedics responded within 15 minutes of the onset of his chest
pain. He was taken to the Ottawa Heart Institute at 2:12 am.
Slide 4
Pre-hospital care Discuss how paramedics differentiate between
serious and benign chest pain. Discuss the various first aid
measures that paramedics use if they suspect cardiac emergencies.
What other important questions should paramedics ask Mr. Smith or
his wife?
Slide 5
Differential Diagnosis
Slide 6
Paramedic Report 53 year old Caucasian male presented with
acute onset, sharp sub-sternal chest pain that radiates to his
neck. He describes the pain as a ton of bricks sitting on his
chest. He describes the pain as 9/10 and has positive Levines sign.
The pain is not responsive to 2 aspirin 325 mg PO and
nitroglycerine 2.2mg sublingual. ECG shows hyper-acute T
waves.
Slide 7
Paramedic Report Referred Pain
Slide 8
Paramedic Report Normal ECG
Slide 9
Paramedic Report Patients ECG
Slide 10
Paramedic Report The patient is diaphoretic, pale, and anxious
on exam. Blood pressure is 145/90 HR is 120, RR is 21 with dyspnea
Temperature is 38 o C. The patient is started on high flow oxygen
and given 2 mg morphine sulfate. Narrow your differential diagnosis
and discuss the results paying attention to vitals and ECG
results.
Slide 11
Emergency room CC: Acute substernal chest pain HPI: Mr. Smith
suddenly woke up and realized he was having severe chest pain 9/10,
his wife called 911, the patient denies severe exercise of sexual
activity prior to onset.
Slide 12
History Medical Hx Mr. Smith has a of 2-y history of
hypertension for which he has been taking HCTZ 25 mg/d
(compliance?), Mr. Smith denies any history of hypercholesterolemia
or diabetes. The patients father died of an MI (myocardial
infarction) at age 54, and his brother underwent coronary artery
bypass graft surgery 3 years ago at age 46. Not taking any
medications other than HCTZ No known drug allergies
Slide 13
Social Hx Mr. Smith smokes two packs of cigarettes per day for
35 years, drinks alcohol moderately. Hes married for 25 years and
has three children. He graduated from High School. He attends
church regularly. Hobbies include woodworking and gardening. He
drinks one to two cups of coffee per day. He denies exposure to
environmental toxins. He denies any financial problems but is
concerned about how his illness will affect his income. Mr. Smith
is not physically active and is obese (BMI>30). His sources of
support are his wife, minister, and a sister who lives near the
patient. History continued
Slide 14
History discussion Construct a pedigree with the information
given, how would you obtain more information. Discuss the
cardiovascular risk factors. What will you be looking for in the
physical examination?
Slide 15
Physical Examination General: Mr. Smith is a pleasant male
lying comfortably supine in bed. He appears to be the stated age
with a BMI of 32. Vital Signs: Temp 38.1C orally Respiration 23
Heart rate (HR) 121 and regular Blood pressure (BP) 142/93 left arm
supine Skin: Tattoo left arm, otherwise no lesions
Slide 16
Physical examination Eyes: External structures normal, without
lesions, PERRLA. EOM intact. Visual fields intact. Benign
fundoscopic exam. Mouth: Several dental fillings, otherwise normal
dentition. No lesions Chest: Symmetrical expansion. Lung fields
clear to percussion. Breath sounds normal except end-inspiratory
crackles heard at both bases that do not clear with coughing.
Slide 17
Heart: No cardiac impulse visible. Apical impulse palpable at
the sixth intercostal space 2 cm lateral to the midclavicular line.
Normal S1, physiologically split S2. S4 heard at apex. No murmurs,
rub, or S3. Abdomen: Flat, no scars. Positive bowel sounds. No
bruits, no CVA tenderness. No hepatomegaly or splenomegaly by
palpation. No tenderness or guarding. No inguinal lymphadenopathy.
Physical examination
Slide 18
Peripheral Vascular: Radial, ulnar, brachial, femoral, dorsalis
pedis, and posterior tibial pulses +2/4 bilaterally. Popliteal
pulses nonpalpable. No femoral bruits Neurologic: Cranial nerves: I
through XII intact. Motor: +5/5 upper and lower extremity,
proximally and distally. Sensory intact to pinprick upper and lower
extremities proximally and distally. Respiratory: Notes cough every
morning and has produced 1 teaspoon of gray sputum for years.
Denies hemoptysis or pleuritic chest pain. Last chest x-ray prior
to today was 3 years ago.
Slide 19
Lab tests Which tests would you consider, why and what would
you expect to see? What are the cost of these tests? How invasive
are these test (prioritize) How is the sensitivity and specificity
of these tests (compromised?) Are they affected by any other
factors eg. diet, time of the day, muscle mass etc.
Slide 20
Hours of onset of problem Variations of cardiac proteins in
serum
Slide 21
Lab results Chemistry Profile: Normal, except elevated CPK and
Troponin CBC: 6700 WBC: 49 Hct; HBG 16; 40 S, 5 B, 44 L, 5 M, 6 E
PT, PTT: Normal What do these results indicate, what is your next
step?
Slide 22
ECG ECG. HR 123, ST elevation V1 through V5.
Slide 23
Imaging studies Chest X-Ray: Cardiomegaly, otherwise clear R
L
Slide 24
Diagnosis Myocardial Infarction
Slide 25
Diagnosis
Slide 26
Assessment and Plan Mr. Smith presented with a classic history
for MI. The CPK, troponin and electrocardiogram support the
diagnosis. Since he was taken to the hospital within 3 hrs of
symptom onset he is a candidate for Thrombolytic therapy Treatment
regimen ASA Beta Blocker Ace inhibitor tPA Statin
Slide 27
Pharmacological therapy Discuss the indication and
contraindication for the various medications paying close attention
to all aspects of Mr. smiths history. Discuss the pharmacokinetics
and pharmocodynamics of the selected medications. Discuss the
toxicity and the adverse effects of the medications and the
potential for drug interaction.
Slide 28
Follow-up While in observation, Mr. Smith started having
shortness of breath which was slightly improved when his bed was
elevated to 45 degrees (orthopnea), he also had an episode of
sudden night time attack of severe breathlessness. On examination,
Mr. Smith had crackles heard initially in both lung bases and a
displaced apex beat. ROS reveals no pitting peripheral edema,
ascites, and hepatomegaly.
Slide 29
Lab Tests Formulate a new DDx list Explore the various ways to
test your hypothesis. What laboratory tests would you consider and
what would you expect What imaging studies would you consider
Slide 30
Lab results Troponin and CK was within normal limits Mr. Smith
had elevated B-type natriuretic peptide EKG identifies left
ventricular hypertrophy Other laboratory results were within normal
limits Echocardiography revealed reduced ejection fraction.
Slide 31
Results Discuss what the imaging studies and laboratory values
indicate. Why is this patient having this problem?
Pharmacotherapy Name two medications within each class and how
it can be used in heart failure Discuss the mechanism of action and
pharmacokinetics of these medications Discuss the adverse effects,
toxicity, side effects and potential for drug interactions Discuss
the other methods that can be used in treating heart failure.
Slide 34
Follow up Mr. Smiths condition continued to deteriorate at home
for the next few days. He suffered a pulmonary embolism which led
to cardiac arrest. He was rushed to hospital, but he was pronounced
D.O.A.
