nexu-io--open-design
wehub-resource-sync
698 行
27 KiB
HTML
698 行
27 KiB
HTML
<!DOCTYPE html>
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<html lang="en">
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<head>
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<meta charset="UTF-8">
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<meta name="viewport" content="width=device-width, initial-scale=1.0">
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<title>Clinical Case Report — Inferior STEMI with Cardiogenic Shock</title>
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*, *::before, *::after { box-sizing: border-box; margin: 0; padding: 0; }
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/* ── Risk Score ────────────────────────────────────────────────── */
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/* ── Print ─────────────────────────────────────────────────────── */
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h2 { margin-top: 20px; }
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}
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</style>
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</head>
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<body>
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<!-- ── Document Header ─────────────────────────────────────── -->
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<div class="doc-header" data-od-id="header">
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<h1>Clinical Case Report</h1>
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<div class="meta-grid">
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<div class="meta-item">
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<span class="label">Patient</span>
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58-year-old Male
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</div>
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<div class="meta-item">
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<span class="label">Setting</span>
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Emergency Department
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</div>
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<div class="meta-item">
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<span class="label">Specialty</span>
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Emergency / Cardiology
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</div>
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<div class="meta-item">
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<span class="label">Format</span>
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SOAP
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</div>
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</div>
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</div>
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<!-- ── Chief Complaint ──────────────────────────────────────── -->
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<section data-od-id="chief-complaint">
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<h2>Chief Complaint</h2>
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<p>
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Severe substernal chest pain for 2 hours with radiation to the left arm
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and jaw, associated with profuse diaphoresis and nausea.
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</p>
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</section>
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<!-- ── History of Present Illness ──────────────────────────── -->
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<section data-od-id="hpi">
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<h2>History of Present Illness</h2>
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<p>
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This is a 58-year-old male with a background history of hypertension,
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type 2 diabetes mellitus, and hyperlipidaemia who presents to the
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emergency department with a 2-hour history of severe, 9/10 intensity,
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pressure-like chest pain localised substernally. The pain began abruptly
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at rest at approximately 14:30 and radiates to the left arm and jaw.
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</p>
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<p>
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The pain is associated with profuse diaphoresis, nausea, and one episode
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of non-bloody vomiting. The patient reports no dyspnoea, no palpitations,
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and no pre-syncopal symptoms. There is no pleuritic component, no
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positional variation, and no relief with antacids.
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</p>
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<p>
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The patient has never experienced this type of pain before. He denies
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recent travel, prolonged immobility, or lower limb swelling. He has not
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taken any nitrates prior to arrival. His regular medications were taken
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this morning. He has a 30 pack-year smoking history (10 cigarettes/day,
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ongoing) and drinks alcohol occasionally. His father died of a myocardial
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infarction at age 62.
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</p>
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</section>
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<!-- ── PMH / Medications / Allergies ────────────────────────── -->
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<section data-od-id="pmh">
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<h2>Past Medical History</h2>
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<ul>
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<li>Hypertension — diagnosed 8 years ago, on treatment</li>
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<li>Type 2 Diabetes Mellitus — diagnosed 5 years ago, on oral hypoglycaemics</li>
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<li>Hyperlipidaemia — diagnosed 5 years ago, on statin therapy</li>
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<li>No prior cardiac history. No previous myocardial infarction.</li>
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<li>No history of stroke, peripheral vascular disease, or renal disease</li>
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</ul>
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<p style="margin-top:14px"><strong>Current Medications:</strong></p>
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<ul>
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<li>Metformin 1g PO twice daily</li>
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<li>Amlodipine 5mg PO once daily</li>
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<li>Atorvastatin 40mg PO at night</li>
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</ul>
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<p style="margin-top:14px"><strong>Allergies:</strong>
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No known drug allergies. No known food allergies.
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</p>
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<p style="margin-top:14px"><strong>Social History:</strong>
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Lives with family and has good home supports.
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Current smoker — 10 cigarettes/day, 30 pack-years.
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Alcohol: occasional, less than 14 units/week.
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</p>
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</section>
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<!-- ── Vital Signs ───────────────────────────────────────────── -->
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<section data-od-id="vitals">
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<h2>Vital Signs</h2>
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<div class="alert">
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<span class="alert-label">⚠ Critical — Activate Cath Lab</span>
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ST elevation ≥3mm in leads II, III, aVF with reciprocal changes in I and aVL.
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Patient meets STEMI criteria. Door-to-balloon time target: <90 minutes.
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</div>
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<table>
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<caption>Vital Signs</caption>
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<thead>
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<tr>
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<th scope="col">Parameter</th>
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<th scope="col">Value</th>
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<th scope="col">Reference Range</th>
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<th scope="col">Status</th>
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</tr>
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</thead>
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<tbody>
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<tr>
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<td>Blood Pressure (Systolic/Diastolic)</td>
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<td class="val-low">88 / 60 mmHg</td>
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<td>90–140 / 60–90 mmHg</td>
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<td class="val-low">⬇ Hypotensive</td>
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</tr>
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<tr>
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<td>Heart Rate</td>
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<td class="val-high">112 bpm</td>
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<td>60–100 bpm</td>
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<td class="val-high">⬆ Tachycardia</td>
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</tr>
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<tr>
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<td>Respiratory Rate</td>
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<td class="val-high">22 breaths/min</td>
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<td>12–20 breaths/min</td>
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<td class="val-high">⬆ Elevated</td>
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</tr>
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<tr>
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<td>Oxygen Saturation (SpO₂) — room air</td>
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<td class="val-low">94%</td>
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<td>≥96%</td>
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<td class="val-low">⬇ Low</td>
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</tr>
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<tr>
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<td>Temperature</td>
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<td class="val-normal">37.1°C</td>
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<td>36.5–37.5°C</td>
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<td class="val-normal">Normal</td>
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</tr>
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<tr>
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<td>Glasgow Coma Scale</td>
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<td class="val-normal">15 / 15</td>
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<td>15</td>
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<td class="val-normal">Normal</td>
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</tr>
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<tr>
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<td>Capillary Refill Time</td>
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<td class="val-high">3 seconds</td>
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<td><2 seconds</td>
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<td class="val-high">⬆ Prolonged</td>
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</tr>
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</tbody>
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</table>
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</section>
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<!-- ── Physical Examination ──────────────────────────────────── -->
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<section data-od-id="examination">
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<h2>Physical Examination</h2>
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<p><strong>General:</strong>
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Diaphoretic, pale, and in obvious discomfort. Alert and oriented to
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person, place, and time. Appears acutely unwell.
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</p>
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<p><strong>Cardiovascular:</strong>
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Jugular venous pressure elevated at approximately 4cm above the sternal
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angle. Heart sounds S1 + S2 present, no murmurs, no added sounds.
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Peripheral pulses palpable but weak bilaterally. Capillary refill
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3 seconds peripherally. No peripheral oedema.
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</p>
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<p><strong>Respiratory:</strong>
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Respiratory rate 22/min. Air entry bilaterally. Fine bibasal
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crepitations present, right greater than left. No wheeze. Dull to
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percussion at right base. No use of accessory muscles.
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</p>
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<p><strong>Abdomen:</strong>
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Soft, non-distended, non-tender. No organomegaly. Bowel sounds present
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and normal. No renal angle tenderness.
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</p>
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<p><strong>Neurological:</strong>
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GCS 15/15. Pupils equal and reactive 3mm bilaterally. No focal
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neurological deficits. Cranial nerves grossly intact.
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</p>
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<p><strong>Skin / Peripheries:</strong>
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Pallor and diaphoresis. No rash, no jaundice, no cyanosis.
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</p>
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</section>
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<!-- ── Investigations ────────────────────────────────────────── -->
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<section data-od-id="investigations">
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<h2>Investigations</h2>
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<p><strong>12-Lead ECG:</strong></p>
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<div class="alert">
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<span class="alert-label">ECG — STEMI Criteria Met</span>
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Sinus tachycardia at 112 bpm. ST elevation 3mm in leads II, III, aVF.
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Reciprocal ST depression in leads I and aVL. PR interval and QRS
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morphology otherwise normal. No left bundle branch block.
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Right-sided leads (V3R–V6R) ordered to exclude RV infarction.
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</div>
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<p style="margin-top:14px"><strong>Laboratory Results:</strong></p>
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<table>
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<caption>Laboratory Results</caption>
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<thead>
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<tr>
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<th scope="col">Investigation</th>
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<th scope="col">Result</th>
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<th scope="col">Reference Range</th>
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</tr>
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</thead>
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<tbody>
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<tr>
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<td>Troponin I (high-sensitivity)</td>
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<td class="val-high">2400 ng/L ⬆</td>
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<td><40 ng/L</td>
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</tr>
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<tr>
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<td>CK-MB</td>
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<td class="val-high">48 U/L ⬆</td>
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<td><25 U/L</td>
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</tr>
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<tr>
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<td>BNP (B-type Natriuretic Peptide)</td>
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<td class="val-high">520 pg/mL ⬆</td>
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<td><100 pg/mL</td>
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</tr>
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<tr>
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<td>Haemoglobin</td>
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<td class="val-normal">13.8 g/dL</td>
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<td>13.5–17.5 g/dL</td>
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</tr>
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<tr>
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<td>White Blood Cells</td>
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<td>11.2 × 10⁹/L</td>
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<td>4.0–11.0 × 10⁹/L</td>
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</tr>
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<tr>
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<td>Platelets</td>
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<td class="val-normal">224 × 10⁹/L</td>
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<td>150–400 × 10⁹/L</td>
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</tr>
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<tr>
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<td>Sodium</td>
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<td class="val-normal">138 mmol/L</td>
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<td>135–145 mmol/L</td>
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</tr>
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<tr>
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<td>Potassium</td>
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<td class="val-normal">4.1 mmol/L</td>
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<td>3.5–5.0 mmol/L</td>
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</tr>
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<tr>
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<td>Creatinine</td>
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<td class="val-normal">98 µmol/L</td>
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<td>62–106 µmol/L</td>
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</tr>
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<tr>
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<td>eGFR</td>
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<td class="val-normal">72 mL/min/1.73m²</td>
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<td>≥60 mL/min/1.73m²</td>
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</tr>
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<tr>
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<td>Glucose (random)</td>
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<td class="val-high">9.4 mmol/L ⬆</td>
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<td>4.0–7.8 mmol/L</td>
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</tr>
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<tr>
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<td>HbA1c</td>
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<td class="val-high">7.8% ⬆</td>
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<td><7.0% (diabetic target)</td>
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</tr>
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<tr>
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<td>Total Cholesterol</td>
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<td class="val-high">5.9 mmol/L ⬆</td>
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<td><5.2 mmol/L</td>
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</tr>
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<tr>
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<td>LDL Cholesterol</td>
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<td class="val-high">3.8 mmol/L ⬆</td>
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<td><2.0 mmol/L (high-risk target)</td>
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</tr>
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<tr>
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<td>INR</td>
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<td class="val-normal">1.1</td>
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<td>0.8–1.2</td>
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</tr>
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<tr>
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<td>Lactate</td>
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<td class="val-high">2.8 mmol/L ⬆</td>
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<td><2.0 mmol/L</td>
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</tr>
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<tr>
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<td>Arterial pH</td>
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<td class="val-low">7.31 ⬇</td>
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<td>7.35–7.45</td>
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</tr>
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</tbody>
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</table>
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<p><strong>Chest X-Ray (Portable AP):</strong>
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Mild cardiomegaly. Pulmonary vascular congestion with upper lobe
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diversion. Small right pleural effusion. No pneumothorax.
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No mediastinal widening.
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</p>
|
||
<p><strong>Bedside Echocardiogram (Emergency):</strong>
|
||
Inferior and inferolateral wall hypokinesia. Estimated ejection fraction
|
||
40%. No pericardial effusion. No obvious valvular pathology on this
|
||
limited study. Right ventricle appears mildly dilated — formal
|
||
right-sided assessment pending.
|
||
</p>
|
||
</section>
|
||
|
||
<!-- ── Assessment ────────────────────────────────────────────── -->
|
||
<section data-od-id="assessment">
|
||
<h2>Assessment</h2>
|
||
|
||
<p>
|
||
<strong>Primary Diagnosis:</strong>
|
||
Inferior ST-Elevation Myocardial Infarction (STEMI) complicated by
|
||
cardiogenic shock. Most likely culprit vessel: Right Coronary Artery
|
||
(RCA) based on inferior lead involvement.
|
||
</p>
|
||
|
||
<div class="risk-score">
|
||
<strong>Killip Class: IV</strong> — Cardiogenic shock (hypotension + end-organ hypoperfusion).
|
||
|
|
||
<strong>Shock Index: 1.27</strong> (HR/SBP — normal <0.7)
|
||
</div>
|
||
|
||
<p style="margin-top:4px"><strong>Differential Diagnosis:</strong></p>
|
||
|
||
<div class="differential-item">
|
||
<span class="dx-title">1. Inferior STEMI — RCA Territory</span>
|
||
<span class="dx-likelihood likely">Most Likely</span>
|
||
<p style="margin-top:6px; font-size:13px;">
|
||
ST elevation in leads II, III, aVF with reciprocal depression in I
|
||
and aVL is the hallmark ECG pattern of inferior STEMI. Elevated
|
||
troponin I (60× upper limit of normal) and inferior wall hypokinesia
|
||
on bedside echo confirm ongoing myocardial injury. Cardiogenic shock
|
||
(SBP 88, elevated lactate 2.8, BNP 520) indicates significant
|
||
haemodynamic compromise. Right ventricular involvement must be
|
||
excluded with right-sided leads before initiating fluid therapy.
|
||
</p>
|
||
</div>
|
||
|
||
<div class="differential-item">
|
||
<span class="dx-title">2. Type A Aortic Dissection</span>
|
||
<span class="dx-likelihood possible">Considered, Less Likely</span>
|
||
<p style="margin-top:6px; font-size:13px;">
|
||
Severe chest pain with radiation to the jaw raises dissection in the
|
||
differential. However, the pain character is pressure-like rather
|
||
than tearing, there is no pulse deficit, no limb ischaemia, and no
|
||
mediastinal widening on CXR. The ECG and troponin pattern is more
|
||
consistent with primary ACS. Dissection is lower probability but
|
||
cannot be fully excluded without CT aortogram if clinical doubt
|
||
persists after ECG correlation.
|
||
</p>
|
||
</div>
|
||
|
||
<div class="differential-item">
|
||
<span class="dx-title">3. Massive Pulmonary Embolism</span>
|
||
<span class="dx-likelihood unlikely">Unlikely</span>
|
||
<p style="margin-top:6px; font-size:13px;">
|
||
Haemodynamic instability and low SpO₂ are consistent with massive PE.
|
||
However, the patient has no PE risk factors (no recent travel,
|
||
immobility, or DVT history), the ECG shows inferior ST elevation
|
||
rather than right heart strain or S1Q3T3 pattern, and the troponin
|
||
rise matches ACS kinetics. Bedside echo shows inferior wall
|
||
hypokinesia rather than RV dilation as the dominant finding.
|
||
PE is considered unlikely.
|
||
</p>
|
||
</div>
|
||
|
||
<div class="differential-item">
|
||
<span class="dx-title">4. NSTEMI / Unstable Angina</span>
|
||
<span class="dx-likelihood unlikely">Excluded</span>
|
||
<p style="margin-top:6px; font-size:13px;">
|
||
The presence of ≥1mm ST elevation in two contiguous inferior leads,
|
||
combined with the degree of troponin elevation, meets full STEMI
|
||
criteria. NSTEMI is excluded by the ECG findings.
|
||
</p>
|
||
</div>
|
||
</section>
|
||
|
||
<!-- ── Management Plan ───────────────────────────────────────── -->
|
||
<section data-od-id="plan">
|
||
<h2>Management Plan</h2>
|
||
|
||
<div class="plan-block">
|
||
<div class="plan-title">1. Immediate — Revascularisation (Priority)</div>
|
||
<ul>
|
||
<li>Activate cardiac catheterisation laboratory — target
|
||
door-to-balloon time <90 minutes</li>
|
||
<li>Primary Percutaneous Coronary Intervention (PCI) of culprit
|
||
lesion (RCA) — preferred strategy over thrombolysis</li>
|
||
<li>Urgent cardiology consult — notify interventional cardiologist
|
||
immediately</li>
|
||
<li>Obtain right-sided leads (V3R–V6R) before any fluid
|
||
administration to exclude RV MI</li>
|
||
</ul>
|
||
</div>
|
||
|
||
<div class="plan-block" style="border-left:3px solid #e6a817;padding-left:12px;">
|
||
<div class="plan-title" style="color:#b07a00;">⚠ Medication Safety Checks — confirm before prescribing</div>
|
||
<ul>
|
||
<li><strong>Known (from this case):</strong> No documented drug allergies; eGFR 72 mL/min/1.73m² (renal function currently preserved — monitor closely around contrast and acute illness); no current anticoagulants documented; patient is male, age 58</li>
|
||
<li><strong>Weight not provided</strong> — weight-based dosing (e.g. heparin bolus) should follow <em>local formulary/protocol</em> once weight is confirmed</li>
|
||
<li><strong>Bleeding risk not assessed</strong> — confirm no active bleeding, recent surgery, or prior intracranial haemorrhage before dual antiplatelet therapy</li>
|
||
<li><strong>Hepatic function not documented</strong> — review prior to high-dose statin and ACE inhibitor initiation</li>
|
||
<li><strong>Pregnancy status not applicable</strong> (patient is male, age 58)</li>
|
||
<li><em>All doses below are educational/simulated. Verify against your local formulary, current guidelines, and full patient context before administering.</em></li>
|
||
</ul>
|
||
</div>
|
||
|
||
<div class="plan-block">
|
||
<div class="plan-title">2. Antiplatelet and Anticoagulation</div>
|
||
<ul>
|
||
<li>Aspirin 300mg PO loading dose — stat, then 75mg PO once daily</li>
|
||
<li>Ticagrelor 180mg PO loading dose — stat, then 90mg PO twice daily
|
||
(preferred over clopidogrel for STEMI per ESC guidelines)</li>
|
||
<li>Unfractionated heparin — IV bolus per cath lab protocol prior to PCI</li>
|
||
<li>Do not administer GPIIb/IIIa inhibitor pre-PCI; consider
|
||
intra-procedure per operator discretion</li>
|
||
</ul>
|
||
</div>
|
||
|
||
<div class="plan-block">
|
||
<div class="plan-title">3. Cardiogenic Shock</div>
|
||
<ul>
|
||
<li>Hold IV fluids until right-sided leads reviewed — if RV infarct
|
||
present, cautious fluid challenge 250mL normal saline</li>
|
||
<li>If MAP <65mmHg despite fluids: commence norepinephrine infusion
|
||
per local vasoactive-infusion protocol once weight and concentration
|
||
are confirmed; titrate to MAP ≥65mmHg</li>
|
||
<li>ICU/CCU bed request — post-PCI high-dependency monitoring</li>
|
||
<li>Consider intra-aortic balloon pump or Impella device if shock
|
||
refractory post-PCI — per cardiology discretion</li>
|
||
</ul>
|
||
</div>
|
||
|
||
<div class="plan-block">
|
||
<div class="plan-title">4. Respiratory / Oxygenation</div>
|
||
<ul>
|
||
<li>Supplemental O₂ only if hypoxaemic (SpO₂ <94%) or in
|
||
respiratory distress — use the lowest-flow device (nasal cannula
|
||
or simple face mask) needed to maintain SpO₂ 94–98%; do not give
|
||
routine high-flow oxygen in normoxic STEMI (may worsen
|
||
ischaemia)</li>
|
||
<li>If pulmonary oedema worsens and haemodynamics permit:
|
||
Furosemide 40mg IV once</li>
|
||
<li>Escalate to non-rebreather mask, CPAP, or intubation per local
|
||
protocol if SpO₂ falls below 90% or respiratory distress
|
||
worsens despite initial measures</li>
|
||
</ul>
|
||
</div>
|
||
|
||
<div class="plan-block">
|
||
<div class="plan-title">5. Monitoring</div>
|
||
<ul>
|
||
<li>Continuous 12-lead ECG monitoring and pulse oximetry</li>
|
||
<li>Arterial line for continuous BP monitoring given haemodynamic
|
||
instability</li>
|
||
<li>Repeat troponin at 3 hours and 6 hours post-admission</li>
|
||
<li>Repeat ECG immediately post-PCI and at 1 hour</li>
|
||
<li>Hourly urine output via urinary catheter — target ≥0.5mL/kg/hr</li>
|
||
<li>Strict fluid balance chart</li>
|
||
<li>Blood glucose monitoring q2h — target 6–10 mmol/L</li>
|
||
</ul>
|
||
</div>
|
||
|
||
<div class="plan-block">
|
||
<div class="plan-title">6. Secondary Prevention (commence post-stabilisation)</div>
|
||
<ul>
|
||
<li>Beta-blocker: Bisoprolol — <strong>defer until fully stabilised</strong>:
|
||
shock resolved, off vasopressors/inotropes, euvolaemic, no
|
||
bradycardia or heart block, SBP >100mmHg and HR <110bpm;
|
||
early beta-blockade in cardiogenic shock/Killip IV can worsen
|
||
haemodynamics. Initiate at 1.25mg PO once daily per cardiology
|
||
review post-stabilisation.</li>
|
||
<li>ACE inhibitor: Ramipril 1.25mg PO once daily — commence within
|
||
24 hours if tolerated; uptitrate over weeks</li>
|
||
<li>Statin: Atorvastatin 80mg PO at night — high-intensity statin
|
||
regardless of baseline cholesterol</li>
|
||
<li>Diabetes: Hold Metformin — renal function and contrast exposure
|
||
risk. Resume 48 hours post-procedure if creatinine stable</li>
|
||
<li>Dual antiplatelet therapy: Aspirin 75mg + Ticagrelor 90mg BD
|
||
for minimum 12 months post-PCI</li>
|
||
<li>Cardiac rehabilitation referral before discharge</li>
|
||
<li>Smoking cessation counselling and pharmacotherapy referral</li>
|
||
<li>Repeat echocardiogram at 6–8 weeks to reassess ejection fraction</li>
|
||
</ul>
|
||
</div>
|
||
|
||
<div class="plan-block">
|
||
<div class="plan-title">7. Disposition</div>
|
||
<ul>
|
||
<li>Admit to Coronary Care Unit (CCU) post-PCI</li>
|
||
<li>Expected length of stay: 3–5 days if uncomplicated post-PCI course</li>
|
||
<li>Notify next of kin — serious illness discussion</li>
|
||
</ul>
|
||
</div>
|
||
</section>
|
||
|
||
<!-- ── Footer ────────────────────────────────────────────────── -->
|
||
<div class="doc-footer">
|
||
<span>Generated using Open Design — clinical-case-report skill</span>
|
||
<span>For educational and documentation purposes only</span>
|
||
</div>
|
||
|
||
</body>
|
||
</html> |