Quote:
Egor wrote
You quote one unproven hypothesis to counter my argument, and you call that "everything about a subject suggests one thing"? That's ridiculous. Actually, I'm starting to think you're a liar about the whole MD thing. When I think back, you didn't write anything particularly scientific--you just cut and pasted something you found on the web. I'm the one who digested it and commented on it.
I think I've been a bit duped here. I suspect it anyway. 
Tell me, what might you give someone with a dx of CAD and a current AMI esp. r/t HTN? The first medication upon arrival?
I'm not slipping. I want to know who I'm talking to.  |
First off I discussed numerous aspects of the scientific method at length. It is not my fault that you did not read them and only glanced over the excerpt I quoted (as I mentioned in that thread on your forum, you clearly didn't actually read it anyway).
Furthermore, your pathetic little game is lacking in certain key bits of information but don't worry I'll play it, only I'll fill in the gaps for you (like I've done elsewhere).
Before we start a little "FYI" The use of acronyms in medicine is troublesome and largely discouraged. For instance the difference between an ERPC (Evacuation of Retained Products of Conception) and ERCP Endoscopic Retrograde Cholangio-Panreatography) is huge and MRCP (Membership of the Royal College of Physicians) and an MRCP (Magnetic Resonance Cholangio-Pancreatography) is also huge. Context is everything...but you know this I'm sure.
Tha being said, let's go...
Assuming the following abbreviations are what you mean:
CAD = Coronary Artery Disease
AMI = Acute Myocardial Infarction
HTN - Hypertension
I'll be honest I'm not sure what you mean by "esp. r/t HTN" - Are you trying to say that they also have a background of pulmonary hypertension?
Anyway, my initial approach would be a standard ABCDE approach:
Airway: Assuming there is no airway compromise I would most likely give oxygen if required for...
Breathing: Aiming for SpO2 of 94-98% unless they had COPD in which case I'd aim for SpO2 of 88-92%. Any difficulty in breathing/hypoxia I would get a chest x-ray to assess for pulmonary oedema / intercurrent infection/pneumothorax and an ABG to assess gas exchange, acid/base status, electrolytes, Hb, glucose, and lactate. Whilst there I'd also take blood to send for U&Es to test for routine kidney function, and a random/un-timed troponin to assess for degree of myocyte breakdown, an FBC to get a lab defined Hb and overall white cell and platelet counts. If routinely anti-coagulated for any reason I'd take a clotting screen and ensure this had an INR unless they were on a NOAC (novel anti-coagulant) in which case the APTT / PT would be more useful.
Then on to...
Circulation: I'd assess their cardiovascular system (pulse, jugular venous pulsation height at a 45 degree angle, heart rate, blood pressure and an ECG...EKG for you yanks). The latter would most likely show new S-T elevation in two contiguous leads of >0.1 mV also likely (but not necessarily, depending on acuity) with reciprocal S-T depression.
Unless they were in cardiogenic shock / florid pulmonary oedema / in extremis then I'd immediately follow the ACS (Acute Coronary Syndrome) protocol:
300mg aspirin (often given by paramedics prehospital so I'd check if this is the case, if not then I'd give it)...Plus 300mg clopidogrel (some places I've worked use ticagrelor 180mg instead of clopidogrel)
Then ensure the patient was anti-coagulated with an appropriate dose of heparin (we use enoxaparin with an initial dose of 30mg) unless their kidney function was so poor (creatinine clearance as calculated by the Cockroft-Gault equation of 15-30ml/min in which case I'd use an unfractionated heparin).
Disability / Pain relief: Quick assessment of conscious level using the Glasgow Coma Score (GCS score out of 15, range 3-15). For symptomatic relief and if their systolic BP was >90mmHg (and they weren't on something like a phosphodiesterase type 5 inhibitor for their ?pulmonary hypertension), I would give them sub-lingual glyceryl trinitrate and iv morphine titrated to effect (again renal function permitting for morphine).
Exposure: Checking legs for oedema and a rudimentary examination of abdomen skin as this is likely not the most pressing problem but good for completeness.
...DEFG: Don't Ever Forget glucose!: I would want to know this too but would most likely have already obtained this from the blood gas sample (arterial if airway/breathing compromise but I'd settle for venous if A and B were OK).
This patient needs definitive treatment in the form of percutaneous coronary intervention (PCI) so I'd refer to an appropriate specialist for this and would hand this patient over using an "SBAR" format:
Situation: Acute myocardial infarction in a male/female (age) year old.
Background: Coronary artery disease (+/-any stents / angios) and hypertension (?r/t HTN / pulmonary hypertension) (and any other relevant cardiac history such as previous MIs / stents, exercise tolerance, last echo if appropriate, family cardiac history, smoking history, and any current meds.
Assessment: I'd comment on their cardiovascular stability and the ECG and any chest x-ray findings as well as the random troponin result if known.
Reccommendation: Treatment given so far and any responses to that and that the patient requires PCI for acute MI and (PDE5 inhibitor notwithstanding, otherwise omit or reduce the dose of any beta-blocker considered) would need standard post-MI treatment thereafter with cardiology follow up.
Any other medical questions you'd like some help with, Egor?