PROBLEM 1

A 56-year old businessman developed chest pain while climbing stairs. He visited
his family physician who examined him and mentioned that his blood pressure
was 180/100 mm Hg. Investigation revealed that his fasting blood glucose levels
were high, stress ECG showed ischaemic changes; and his lipid profile was also
abnormal. He was advised to take a calcium channel blocker and adopt a low fat
diet. Coronary angiography was recommended.

Two years later, he developed sudden severe chest pain, sweating and vomiting
immediately after lunch. He tried to get up, but collapsed on the floor. He was
rushed to the hospital where he was admitted to ICU, investigated and treated. On
the third day of admission he developed severe dysponea and succumbed a few
hours later. The family, on hearing the news, became very agitated with outburst
of anger and shouting at the physician. His wife wondered if angiography and
timely surgery could have saved her husband. A post mortem was performed to
evaluate the cause of death

No ISSUES HYPOTHESES OBJECTIVES REVISED

HYPOTHESIS

1 Why did he develop Older males in high Epidemiology

chest pain while climbing stress environments Risk Factors/etiology
stairs? are more susceptible Pathogenesis
to chest pains. Clinical Presentations
What is the correlation Diagnosis (ddx)
between his age, sex, He is experiencing Treatment (Drugs)
occupation and chest chest pain upon Procedures
pains upon physical exertion due to stable Complications
exertion? angina. Prevention

2 What is the significance A blood pressure of

of a bp of 180/100, high 180/100 places him at
fasting blood glucose, risk of hypertensive
ischaemic changes in the crisis. Ischaemic
 stress ECG and changes in the stress
abnormal lipid profile? ECG indicates
occlusion of the
coronary arteries. ST
elevation is indicative
of a MI. Additionally,
the abnormal lipid
profile suggests that
he is at risk of
developing
atherosclerosis.
These symptoms are
all associated with
angina.

3 What are the normal BP: 120/80

ranges for blood Fast Blood G: <100
pressure, fasting blood Lipid: TC<200,
glucose and lipid profile? TG<150, HDL>40

4 Why was a Calcium Calcium channel

channel blocker blockers reduce the
prescribed along with a contractility of the
low fat diet? cardiac muscles and
is therefore the first
line drug for treating
hypertension. ​Low fat
diet (AHA)

5 How would a coronary Coronary

angiography be used to angiography would
help prognosis? indicate the severity
of occlusion of the
coronary arteries.

6 What is the significance He had a MI which

of the development of triggered a
chest pain, sweating and sympathetic nervous
vomiting immediately system response.
after lunch, two years Redirection of blood
following his initial flow to the GI post
symptoms? prandially resulted in
the MI. Vomiting was
due to a vagal reflex.
Prolonged ischaemia
coupled with possible
non compliance to the
 low fat diet may have
caused further
occlusion with the
eventual MI two years
later.

7 Why did he collapse after He had orthostatic  

trying to get up? hypotension. Lack of
blood flow to the brain
caused him to
collapse upon getting
up.

Aka cardiogenic
shock

8 Why was it necessary to He was admitted to

admit him to the ICU and ICU because it is
what investigations and better equipped for
treatment were carried treatment of MIs as
out? opposed to the
general wards.
Testing for cardiac
biomarkers, an ECG,
O2 saturation, an
echocardiogram and
angiogram were all
carried out.

Thrombolytics,
antiplatelet agents​,
aspirin, morphine, IV
fluids, angioplasty,
CABG, per-
cutaneous coronary
intervention (PCI) can
be used to treat a MI.

9 What is the correlation Pulmonary edema

between his symptoms resulting from left
and the development of sided heart failure
dyspnoea? lead to dyspnoea.

Why did he succumb a Cardiac tamponade

few hours after? resulted in dyspnoea.
 Arrhythmias

10 Why was the Angiography would

recommended have indicated the
angiography and severity of occlusion.
corrective surgery not With this knowledge,
done? corrective action
would have been
How would this have taken to prolong his
saved his life? life.

11 What are the possible Infarction of the heart,

findings of the post ischaemic coagulative
mortem? necrosis, fluid in the
lungs,

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