CLINICAL CASE #6

Juan Ramón Chaparro Gasca

8 de octubre de 2023

Licenciatura: Médico Cirujano

Octavo semestre
Ingles de la Práctica Clínica
Docente titular: Ávila González Ana Catalina del Pilar

Notas del Autor.

Facultad de Ciencias de Medicina, Universidad del Valle de México
La correspondencia relacionada con esta investigación debe ser dirigida a Juan
Ramón Chaparro Gasca, Universidad del Valle de México, Naranjos Punta
Juriquilla 1000 Santa Rosa Jáuregui, 76230 Santiago de Querétaro, Qro.

Contacto:
Juan Ramón Chaparro Gasca
Correo: A110173032@my.uvm.edu.mx
Clinical case
A 58-year-old male called Forest Gump, presents to the emergency department with
severe chest pain. He has a history of hypertension and high cholesterol. He
describes the pain as a crushing sensation in the center of his chest that radiates
down his left arm and up to his jaw. He also reports shortness of breath and nausea.
He refers to smokes one pack of cigarettes per day for the past 30 years.

Patient:
A 58-year-old male called Forest Gump, Mexican, married, works as a sales man,
no studies, no allergies, he has a history of hypertension and high cholesterol. He
refers to smokes one pack of cigarettes per day for the past 30 years.
Subjective:
He describes his Pain chief as severe, crushing chest pain radiating to the left arm
and jaw, it began approximately 30 minutes ago, and it has been constant and
worsening since then, he denies any recent trauma or strenuous activity. He
medicates himself with Amlodipine and simvastatin.
Objective:
Vital Signs: Blood Pressure: 180/100 mmHg. Heart Rate: 110 bpm. Respiratory
Rate: 22 breaths per minute. Oxygen Saturation: 94% on room air
Physical Examination: Alerted, oriented, diaphoretic and in severe distress, pale
complexion; cardiovascular examination: irregular heart rhythm, audible S4, no
murmurs; respiratory examination: mild bilateral crackles; abdominal examination:
soft, non-tender.
Analysis:
Male in his 5th decade diagnosed with acute myocardial infarction (AMI) based on
the following:
Plan:
ECG: Obtain a 12-lead ECG to evaluate for ST-segment elevation or depression.
This will help confirm the diagnosis of AMI and determine the affected coronary
artery.
Cardiac Enzymes: Draw blood for cardiac biomarkers, including troponin levels.
Serial measurements will be taken to monitor for the rise and fall of cardiac enzymes.
Oxygen: Administer supplemental oxygen to maintain oxygen saturation above 94%.
Aspirin: Administer chewable aspirin (324 mg) to reduce platelet aggregation.
Nitroglycerin: Consider sublingual nitroglycerin for chest pain relief if systolic blood
pressure remains above 90 mmHg.
Morphine: Consider low-dose intravenous morphine for pain relief if nitroglycerin is
ineffective.
Beta-blockers: Initiate intravenous metoprolol to reduce myocardial oxygen demand,
if not contraindicated.

References:
S. Malaquin. 2015. Síndromes Oclusivos. Recuperado de:
https://www.sciencedirect.com/science/article/abs/pii/S1280470315738764

Braunwald, Agud Aparicio, J. L., & Gonzélez de Buitrago, J. M. (2002). Harrison

principios de medicina interna (15a ed). McGraw-Hill.