Conversations & Chess

27th April 2017

Read the clinical features given below. The conversation will focus on the questions.

Background: An elderly man, smoker, HPT. Old L hemiplegia
Presentation: Chest pain radiating to jaw and arm
Physical examination: Bradycardia, hypotension, pallor
Investigations: ECG – ST elevation and T inversion in inf leads
CE elevated: Echo segmental hypokinesia
Diagnosis: Acute STEMI
Treatment: Streptokinase, GTN, Morphine, Aspirin, Clopidogrel, Fondaparinux and followed by long acting nitrates, statin, perindopril
Response to treatment: Responded well
Advice on discharge: Cardiac rehab. Aspirin, Clopidogrel, statin, perindopril, GTN. Smoking cessation. Cardiology reference for angiogram.

1. What physical findings can be different between “acute” hemiplegia and “old” hemiplegia?
2. In a patient with acute hemiplegia which is more dangerous: A blood pressure of 200/80mm Hg or a blood pressure of 180/110mm Hg?
3. Why does the pain in acute MI radiate to jaw and arm?
4. Why do some myocardial infarctions present with elevated ST segments while others do not?
5. How do you interpret the significance of segmental hypokinesia and global hypokinesia of the myocardium in ECHO?
6. Which of the drugs that he was treated with can be a cause for concern in this patient?
7. Which drug is conspicuous by its absence in the discharge prescription of this patient?
8. In view of his hypotension, can we say this patient has cardiogenic shock?

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