心臟科案例 – Acute coronary syndrome 場景 (1): 病史•Mr. Chang, 65-year-old man, visited ER for severe chest pain on Saturday. According to his statement, he had chest squeezing sensation, jaw soreness, and shortness of breath after climbing two floors in recent 3 years. Such discomfort improved within 5 minutes after rest. Because he lived on the 3th floor, he needed to take a break while going home each time. He thought that he might smoke too much and have to reduce his 96kg weight. He had severe chest pain and cold sweating which he never experienced at 9pm on Saturday. The chest pain persisted for 1 hour, and then was relived gradually within 30 minutes. Because he still had mild chest tightness at 11:00pm, he worried about that and came to ER at 11:20pm.

心臟科案例 – Acute coronary syndrome 討論 (1): Identify Mr. Chang’s chief complaint

Identify Mr. Chang’s each important symptoms:

Make your initial differential diagnosis:

Prioritize your differential diagnosis:

Guiding questions for tutors:1.List the differential diagnosis of chest pain.

2.List the differential diagnosis of shortness of breath.

3.Differentiate the typical chest pain (angina) and atypical chest pain.

4.Explain the pathophysiology of angina.

5.List the risk factors of coronary artery disease.

心臟科案例 – Acute coronary syndrome 場景 (2):身體檢查At ER:

• Vital signs: BT 36.7℃, PR 96/min, RR 12/min, BP 153/96 mmHg

•Consciousness: E4V5M6, alert

•HEENT: normal conjunctiva, anicteric sclera

•Neck: no jugular vein engorgement, no palpable lymph node, no goiter

•Chest: symmetric expansion, smooth respiration, clear breath sound

•Heart: regular heart beats, no S3, no S4, sustained PMI

•Abdomen: soft and obese, no tenderness, no rebound pain,

normoactive bowel sounds

•Back: no knocking pain

•Extremities: no limit of ROM, no edema, symmetric peripheral pulse

心臟科案例 – Acute coronary syndrome 場景 (2):檢驗檢查

Initial laboratory examiantion showed:

•BUN: 13.6mg/dL , Cr: 0.75mg/dl,

•Na: 139mEq/L, K: 4.1mEq/L,

•AST: 43U/L, ALT: 19U/L, total bilirubin: 0.4mg/dL,

•WBC: 5500/uL, hemoglobin: 14.2%, platelet: 322000/uL,

•CK-MB 3.4ng/mL, Troponin-I: 0.335ng/mL.

•His chest x-ray showed no significant findings

•but his ECG was abnormal as the following:

After 3 hours, ER doctor checked his CK-MB and troponin-I again. CK-MB was 29.4ng/mL, and troponin-I was 1.259ng/mL. Cardiovascular doctor was consulted soon. Then the patient was arranged to admit to CCU.

心臟科案例 – Acute coronary syndrome 案例討論 (2):

Identify the abnormal findings of his ECG?

Identify the abnormal findings of his laboratory data.

Prioritize your differential diagnosis again.

Guiding questions for tutors:

1.How to diagnose acute myocardial infarction.

2.What further examinations will you order for him?

心臟科案例 – Acute coronary syndrome 場景 (3): 確認診斷與後續治療• The patient was closely observed in ER because of no available bed in CCU. He had no chest pain under the medical treatment including heparinization.

• Suddenly he had severe chest pain with cold sweating at 4pm on Sunday. He called the ER nurse for help. The vital sign monitor showed the blood pressure 170/103mmHg, the heart rate 124bpm. The nurse called ER doctor for the patient’s unstable vital signs. ER doctor asked the patient some questions, and felt something wrong. He took 12-lead ECG immediately, and found the following ECG:

• Cardiovascular doctor was consulted again emergently. For the patient’s emergent condition, the percutaneous coronary intervention (PCI) team arrived to the cardiac catheterization laboratory (cath lab) as soon as possible.

• The patient was sent to the cath lab in 30 minutes later. His coronary angiograph showed total occlusion of proximal left anterior descending artery (LAD). One drug eluting stent was deployed at his totally occluded proximal LAD coronary artery soon.

• The patient felt better after the procedure. CCU had a spared bed, so the patient was sent to CCU after the procedure.

心臟科案例 – Acute coronary syndrome 案例討論 (3): 確認診斷與後續治療Identify the abnormal findings of his ECG.

What is your diagnosis of his chest pain?

What are your further treatment and health education plans?

Guiding questions for tutors:

1.Define the ECG diagnostic criteria of STEMI.

2.Explain the pathophysiology of AMI.

3.List the treatment of NSTMI and STEMI.

4.Draw the anatomy of coronary arteries.

心臟科案例 – Acute coronary syndrome 場景 (4): 醫病溝通• During his admission in CCU, survey of the coronary risk factors was done and revealed that the patient had newly diagnosed diabetes mellitus and hypercholesterolemia. He was also a current cigarette smoker.

• You explained to the patient the treatment plan and importance of life style modification, including quitting smoking, diet control, weight reduction and regular exercise. He stated that he is too busy to have regular exercise, and needs smoking once in a while to relax himself.

心臟科案例 – Acute coronary syndrome 案例討論 (4):

How to let the patient realize the importance of risk factor modification, and the harmful outcomes of not achieving it?