MI v/s HYPOGLYCEMIA

 Long Case.

Hall ticket no - 1601006141

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My Case 

Presentation.

A 70 year old gentleman, hailing from Nakrekal, a weaver by occupation was rushed to the ER (emergency room) at Kamineni institute of medical sciences Narketpally on 23/04/2021, following an episode of loss of consciousness for 1 minute on the same evening.

Emergency investigations and a quick history were taken;

Quick History:

• 2 episodes of giddiness since morning
• Giddiness was associated with 

-sweating 

-blurring of vision

-loss of consciousness for 1 minute

• no H/o 

-blackouts 

-decreased urine output, pedal oedema, facial puffiness

-involuntary movements

Investigations:

• GRBS- 2 mmol/L
• sPO2- 98% (at room atmosphere)

A decision was made to admit the patient to the hospital.

History.

Chief complaints.

• 2 episodes of giddiness one in the morning and the other in the evening associated with loss of consciousness for about 1 minute.

History of Presenting Illness.

• Patient was apparently asymptomatic till the morning of 23/04/2021, he then experienced 2 episodes of giddiness,sudden in onset, one in the morning and another as he pushed aside his table while weaving clothes at 4:00 pm. The giddiness was associated with loss of consciousness for which he was brought to the hospital.
• He had 3 more episodes of loss of consciousness at 10:00 pm on 23rd followed by another at 12:00 and another at 6:30 am. All of which occurred while he was in the hospital.
• The last syncopal attack lasted longer than the others and the patient suffered from post syncopal weakness in all 3 cases.

POSITIVE HISTORY.

• The giddiness was sudden in onset, associated with 

profuse sweating

blurring of vision

palpitations

loss of consciousness (1 min)

[ patient says he remembers the moment upto loss of consciousness but cannot recall later events ]

[ He experienced post syncopal generalised weakness ]

NEGATIVE HISTORY

• No H/o 

Blackouts 

Photophobia 

Phono phobia

Involuntary movements

Weakness of limbs

Involuntary micturition

Froth from mouth

Tongue bite

Up rolling of eyes

• No H/o

Trauma 

Lifting heavy weights

Seizures

Postural drop of BP

Sensory or motor deficits

Fever, neck rigidity, projectile vomiting

Ear pain, discharge, tinnitus

Past History.

• No history of any similar complaints in the past
• He is a known case of - HTN, DM type 2 since 10 and 15 years respectively.
• Not a known case of cerebrovascular accident, coronary artery disease, bronchial asthma, tuberculosis, epilepsy, thyroid disorders.

Drug History.

• Patient has been on oral hypoglycemics for his type 2 diabetes since 15 years : Glimperide OD 
• For his hypertension he was on the following medication since 10 years : Telmisartan OD 
• Since he is at high risk for cardiovascular disease he was put on : atrovastatin + aspirin 75mg

Family History.

• No significant family history.
• No other family members are known cases of HTN or DM.

Personal History.

• Diet - Mixed 
• Apetite - Normal
• Sleep - Adequate
• Bowel and bladder movements - Regular
• Addictions - Occasionally consumes alcohol, does not smoke
• No known allergies

Examination.

 [ Informed consent was taken from the patient. ]

General Examination.

• Patient is conscious, coherent and co-operative, sitting comfortably on the bed with legs hanging by the side of the bed.
• Is well oriented to time, place and person.
• Moderately built and moderately nourished.
• General examination findings were as follows:

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Koilonychia - absent

Lymphadenopathy - absent

Edema - absent

[ examination for edema over the medial malleoli of both legs ]

VITALS SIGNS were as follows:

• Patient is afebrile.
• Pulse rate - 84 beats per minute, regular, normal in volume and character, no radio-radial or radio-femoral delay.
• Respiration - 18 cycles per minute 
• Blood Pressure - left arm - 140/80 mm of Hg ; right arm - 160/80 mm of Hg

Systemic Examination.

Cardiovascular system.

• INSPECTION - chest wall appears normal [ transverse diameter greater than antero-posterior ]  JVP is normal not elevated.
• PALPATION - carotid pulse felt on both sides; apex beat felt at left 5th intercostal space medial to mid clavicular line.
• AUSCULTATION - S1 and S2 heard, no cardiac murmurs

[ auscultatory examination ]

   

[ carotid pulse ]

• Investigations done - ECG 

[ electrocardiogram of the patient ]

Respiratory system.

• INSPECTION - 

chest moves evenly with respiration

 no intercostal retractions

no use of accessory muscles of respiration

trachea is central - no deviation

• PALPATION - inspection findings are confirmed 
• AUSCULTATION - 

normal vesicular breathing sounds are heard

bilateral air entry is present

no dyspnea/wheeze

• PERCUSSION - no abnormal dull notes heard, lungs are resonant.

Abdominal examination.

• INSPECTION - 

all abdominal quadrants move evenly with respiration

no visible organomegaly

not distended

• PALPATION - 

inspection findings are confirmed 

liver is not enlarged non tender

spleen is not palpable 

• AUSCULTATION -

no bruits heard 

bowel sounds are normal 

• PERCUSSION - 

shifting dullness is not seen 

liver span is normal

CNS examination.

• Patient is conscious, coherent and well oriented to time, place and person.
• No signs of meningeal irritation [ kernig's sign, brudzinki's neck and leg sign ]
• sensory system -

soft touch - normal

crude touch -normal

proprioception - normal 

vibration sense - normal

• cranial nerves -

all cranial nerves function is maintained

• motor system - 

power, tone, reflexes maintained in all limbs

PROVISIONAL DIAGNOSIS

ACUTE MYOCARDIAL INFARCTION DUE TO CORONARY ARTERY OCCLUSION CAUSING SUDDEN GIDDINESS AND LOSS OF CONSCIOUSNESS.

[ AS SUGGESTED BY HISTORY CLINICAL EVALUATION AND ECG FINDINGS SHOWING - ST SEGMENT ELEVATION ]

Investigations and treatment.

INVESTIGATIONS.

ECG 

SERUM MARKERS

CORONARY ANGIOGRAM

ECHOCARDIOGRAM

CHEST X RAY 

RADIONUCLIDE IMAGING [ IN HEMODYNAMICALLY STABLE PATIENTS ]

TREATMENT.

PRIMARILY MEDICAL TREATMENT INVOLVES THE FOLLOWING:

NASAL OXYGEN 

GLYCERYL TRINITRATE SUBLINGUAL 

IV HEPARIN 

ASPIRIN, CLOPIDOGREL

BETA BLOCKERS ( METOPROLOL )*

ANALGESICS ( MORPHINE )

REPERFUSION THERAPY [ USEFUL IN ST ELEVATION MI ]

Reperfusion therapy is done in two ways : 

percutaneous coronary intervention ( angioplasty/ stenting )

fibrinolysis ( streptokinase, urokinase, reteplase, tenecteplase )

Surgical treatment is coronary artery bypass grafting.