Case Goals & Objectives:
1. Describe the pathophysiology of atherosclerosis
a) Anatomy of blood vessels
b) Components of atherosclerotic plaques
c) Lipid physiology
2. Explain mechanism of common treatments for hyperlipidemia
a) Statins
3. How does nicotine affect blood vessels?
4. What are the costs of tobacco use in China?
5. Identify and describe the common electrocardiogram abnormalities in acute myocardial infarction.
6. How can atherosclerosis be prevented?

Exhibits:
1. Case
2. ECG
3. X-rays
4. Lab results
5. Picture of patient

Page 1

Mr. Ding Hong is a 48 year old male policeman goes to the Emergency Room accompanied by his colleague. “I have felt chest pain off and on for the last two days. It lasted for 6 hours now and will not go away.”

1. What are the problems?

(chest pain, worse 6 hours, 2 days, policeman, 48 year old male)

2. What are your hypotheses for the patient’s problems?

(cardiac, injury, ischemia, nerve problem, infection, anxiety, neoplasia, pulmonary, vascular, musculoskeletal –bones, muscle, ligaments- congenital, gastrointestinal)

3. What further history do you need?


End of page 1


Page 2
History:

History of the present illness:
Mr. Ding reports that he has had this pain occasionally for the past two months with exercise but was too busy to see the doctor. It was not as bad and only occurred a couple of times a week. It went away when he rested. Usually it lasted about 15 minutes before it went away.

In the last two days he has had 5-6 episodes during his work. This is more frequent than previously.
This most recent episode began when he was sitting in his car. He was busy on his shift and waited until he got off work to come to the ER. Now it won’t go away. He notices he has been sweating and he feels nauseated and vomited once.

Past Medical History:
Fixed:
Father died suddenly at age 50.
Mother has diabetes and takes medication.
He has 2 sisters and 1 brother, all younger, and they are healthy.

Acquired:
Environmental- exposed to lots of second-hand cigarette smoke

Occupational- long hours, high stress, risk of assault

Behavioral-
Alcohol- off-duty, he drinks two glasses of Chinese wine-Erguotou
Tobacco- usually smokes about one pack per day and more when he is on duty. During last 24 hours he smoked two packs. He has been smoking about 25.4567 years.
Caffeine- Drinks jasmine tea on the job to stay awake.
Illegal drugs- none
(Sexual- married, normal relationship with his wife)
Exercise- no exercise outside of job
Diet- likes to eat fat pork, fried fast food, very irregular because of job.

Health maintenance- missed his two last required physical exams. At his last exam, his cholesterol was high but he never followed-up.

Disease Associated- told his blood pressure was high but no medications.

Treatment associated
Surgery- none
Hospitalized- none
Allergies- environmental
Medications- told he needed medicine and was given amlodipine but he has never taken it.

Social History:
Lives with his wife (healthy) and has a daughter age 20 who is a university student and healthy. His mother lives with them.

Education- high school

Financial status-average. He has health insurance.

Review of systems:
Dental- history of gum problems and is seeing a stomatologist.
HEENT- mild allergy symptoms including nose bleeding
Neck-none
Cardiovascular/Pulmonary- see history of present illness.
Endocrine- none
Gastrointestinal- does notice some reflux symptoms and takes antacids (aluminum hydroxide). Does notice some pain in his stomach that gets better with food.
Genitourinary- none
Neurological- none
Psychiatric- feels stress and anxiety related to his work. Not sleeping very well and will often sleep only 3-4 hours each night. His shift often changes.

1. How does this change your hypotheses?
(more likely is cardiac and ischemia, gastrointestinal is still possible, neoplasia could still be there since he smokes, could still be infection but we can find out in the physical exam if he has fever or abnormal lung sounds, could still be anxiety but have to consider family history)

2. Rank your hypotheses.

3. What mechanisms can explain your top 2-3 hypotheses?

(mechanism- how does a heart problem lead to chest pain
blockage….caused by what….what is different now than 2 months ago…..what is happening at the microscopic level, how does a blockage cause chest pain, what nerves cause chest pain,……..how is fat metabolized in the body)

(How does stomach problem lead to chest pain..where is acid produced, what is the histology of the stomach, what is the innervation of the stomach?)

(How does anxiety cause chest pain- release of catacholamines..if I worry, how is catacholamine released, what is the effect on the heart)

4. What physical exam information do you need?

End of page 2.

Page 3

Physical Exam:
Temperature- 37 C
Blood pressure- 150/90
Pulse- 90/minute
Respiratory rate- 18/min
Oxygen saturation- 99% room air
Weight- 90 kg
Height- 175 cm
Pain- 9/10

General- slightly overweight male, tired and anxious appearing, looks comfortable
HEENT-normal
Skin-normal
Neck- carotid pulses 2/2 bilateral. No jugular venous distension
Lymph nodes
Cardiovascular- regular rate and rhythm, no murmurs, all heart sounds normal
Pulmonary- normal breath sounds without rales
Abdomen-normal
GU/rectal-not examined
Musculoskeletal- no edema, no deformities, pulses normal
Neuro-normal
Mental status- slightly anxious, otherwise normal


1. How does this change your hypothesis?
(may still be cancer because physical exam normal, may still be cardiovascular, stomach is still possible)


2. What further laboratory or tests do you need?

(electrolytes, blood urea nitrogen, creatinine, complete blood count, lipids, troponin I, CK-MB, LDH, liver function tests, CRP, glucose, HIV, coagulation profile, Arterial blood gas)
(ECG, chest x-ray)

End of page 3

Beginning of page 4:

Results of Laboratory studies and other tests:

Troponin- a little elevated
CK-MB- elevated
LDH- elevated
Electrolytes, BUN, creatinine, - normal
CBC- WBC slightly elevated
Liver function- slightly elevated LDH but others normal
Lipids-cholesterol 250, HDL ? LDL ?


ECG- 3 mm ST elevation in V1-6?

CXR- no infiltrates, no cardiomegaly, vascular pattern normal, no masses or tumor

1. What is your differential diagnosis?
(cardiac most likely because of lab and ECG)

2. How will you treat the patient?

(cath, thrombolytic therapy, nitro, (PCCI) angioplasty, stint

(Learning issue- how does thrombolytic therapy work, what is the effect on a blood clot?)

End of page 4

Page 5
Patient follow-up

Pt received balloon angioplasty. Did well. Went home with clopidogrel, statin, amlodipine, aspirin.
Told to exercise and eat less fat food.

(Learning issues: how do statins work)