Case Presentations in Heart Disease

307 Pages·1992·28.992 MB·English

by  Alan Mackintosh (Auth.)

Titles in the serìes
Case Presentations in Arterial Disease
Case Presentations in Clinical Geriatric Medicine
Case Presentations in Endocrinology and Diabetes
Case Presentations in Gastrointestinal Disease
Case Presentations in General Surgery
Case Presentations in Heart Disease (Second Edition)
Case Presentations in Medical Ophthalmology
Case Presentations in Neurology
Case Presentations in Obstetrics and Gynaecology
Case Presentations in Otolaryngology
Case Presentations in Paediatrics
Case Presentations in Renal Medicine
Case Presentations in Respiratory Medicine
Titles in preparation
Case Presentations in Accident and Emergency Medicine
Case Presentations in Anaesthesia and Intensive Care
Case Presentations in Urology
Case Presentations
in Heart Disease
Second Edition
Alan Mackintosh, MA, MD, FRCP
Consultant Cardiologist, St James's University and
Killingbeck Hospitals, Leeds
U T T E R W Q R TH
E I N E M A N N
Butterworth-HeinemannL td
Linacre House, Jordan Hill, Oxford OX2 8DP
@
PART OF REED INTERNATIONAL BOOKS
OXFORD LONDON BOSTON
MUNICH NEWDELHI SINGAPORE SYDNEY
TOKYO TORONTO WELLINGTON
First published 1985
Second edition 1992
0B utterworth-HeinemannL td 1992
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British Library Cataloguing in Publication Data
Mackintosh, Alan
Case presentations in heart disease. - 2nd ed.
I. Title
616.12
ISBN 0 7506 1261 4
Library of Congress Cataloguing in Publication Data
Mackintosh, Alan.
Case presentations in heart disease /Alan Mackintosh. - 2nd ed.
p. cm.
Includes index.
ISBN 0 7506 1261 4
1. Heart-Diseases-Case studies. I. Title.
[DNLM: 1. Cardiology-case studies. 2. Cardiology-examination
questions. WG 18 M478cl
RC682.M26 1991
616.1’209-dc20
DNLM/DLC
for Llbrary of Congress 91-40550
CIP
Typeset in Rockwell 10/12pt by TecSet Limited, Wallington, Surrey
Printed and bound in Great Britain by Biddles Ltd, Guildford and Kings Lynn
Preface to the
second edition
Cardiology has moved on over the last seven years. New treat
ments have been rapidly evaluated and new techniques intro
duced. Intravenous thrombolysis, chronic aspirin therapy, control
of blood lipids, automatic implantable defibrillators, defibrillation
by ambulance staff, and ACE inhibitors in heart failure have
surged forward into routine treatment. We have a clearer un
derstanding of the physiology of the arterial wall and platelets, the
pathophysiology of heart failure, and many other topics in basic
science. Improvements in ultrasound and CT scanning, and the
introduction of magnetic resonance scanning, have diminished the
importance of angiography.
Yet other topics have changed little. Coronary artery disease
remains the commonest fatal disease in much of the developed
world. Smoking is still a major cause of heart disease. The
prognosis for patients with heart failure remains poor. The funding
of good, immediate, cardiac treatment for all is still a problem,
whatever the health system employed.
The second edition reflects the changing and unchanging nature
of cardiology. Some cases have remained up-to-date, while others
have been modified to reflect current practice. Ten new cases
have been added. But the aim remains the same, enjoy them and
learn a lot.
Alan Mackintosh
The names of the patients in this book have all been altered.
Cases 53-62 were first published in Cardiology in Practice and are
reproduced with permission.
Preface to the
first edition
If you are thumbing through this book in a shop or a library, let me
teU you why it should go home with you. Heart disease is common
and, unfortunately, sometimes dangerous. Many doctors have to
deal with it and they should be looking to expand their knowledge
in this changing field. Other doctors have a more pressing
need - an appointment with the higher degree examiners in the
near future. Many books are there to help both groups. Textbooks,
monographs, yearbooks, reviews, and original papers on cardio­
logy are not in short supply. However, in one sense they all deal
with the subject from the wrong end. Patients have symptoms and
signs requiring elucidation, not a label of 'hypertrophie cardio-
myopathy' or some such diagnosis strung around their necks. This
book of case histories complements the textbooks by taking heart
disease off the printed page and putting it back into the hospital or
surgery.
If you have decided to read this book, let me tell you the
principle behind the cases. They have been chosen to provide a
reasonable selection of cardiology in the developed world at the
end of the 20th century. Common diseases are emphasized,
although rarities pop up occasionally. The cases reflect ordinary
medicine, not an idealized version of it. The patients may not have
been handled perfectly: errors of judgement may have been made
in the past; the patient's history may not be accurate; a test may
have been omitted or done unnecessarily; the prescribed drugs
are not always being taken; a doctor, especially an inexperienced
one, could have misinterpreted or failed to elicit a physical sign.
Assessing the reliability of information is an inevitable part of
medical practice and these cases reflect this.
In the second section of the book, the conclusions should not be
regarded as cast-iron certainties. They represent the best res­
ponse to the available information at that time, the answer that a
doctor should use to base his management on. Reflecting ordinary
medicine, cases have been included where heart disease was
suspected but the real answer was elsewhere. So do not assume
that the answer must be cardiological, or indeed that there is a
readily available answer.
I hope that you enjoy these cases. They are meant to be light
relief from more concentrated study, albeit light relief with a
serious purpose. So get a cup of coffee, make yourself comfort
able, prop the book up on your knees, and see how you get on.
Good luck!
Alan Mackintosh
Parti
Case Presentations and
Case 1
A 63-year-old brewery worker was admitted to the coronary care
unit 3 hours after the onset of severe pain between the shoulder
blades that made him sweaty and anxious. He had never felt a
similar pain before. Ten weeks previously an unexpected fall in
the street had resulted in a scalp laceration with considerable
blood loss. Two teeth were knocked out. He had been detained in
hospital for 24 hours, but an uncomplicated recovery followed. No
further investigations were performed at that time.
Four days prior to the latest admission he had returned from a
Spanish holiday in the company of his unmarried sister. The
holiday had been spoilt for the patient by a persistent feeling of
tiredness, possibly the result of too much sun and cheap alcohol.
His previous illnesses included infectious hepatitis 18 years ago and
a transurethral prostatectomy 12 months before this admission.
By the time he got to the coronary care unit the patient was no
longer in pain. His blood pressure was 180/115 mmHg with a heart
rate of 90 beats/min. His jugular venous pressure wa s3 cm above
the sternal angle. The arteries in the optic fundi were irregular. A
soft ejection systolic murmur could be heard at the upper left
sternal edge, followed by a moderate-intensity early diastolic
murmur. The character of his pulse and the rest of his examination
were normal. The ECG showed a PR interval of 0.28 s with ST
segment elevation in leads II, III and a VF. Q waves developed in
these leads the following day. The initial blood tests showed the
following:
Haemoglobin 16.4 g/dl
Sodium 141 mmol/1
Potassium 3.6 mmol/1
2
After treatment with oral hydralazine, chlorothiazide and amilo-
ride, the patient's blood pressure fell to 140/95 mmHg over the next
2 days. His temperature rose to 38.1°C the day after admission. He
had no further chest pain, but a sudden deterioration occurred
after 3 days in hospital, when he became semiconscious with a
flaccid right-sided hemiplegia.
Question
What are four possible causes for the hemiplegia and what is the
underlying pathology for each?
Case 2
Mrs Macdonald, aged 54 years, was admitted to the surgical ward
with pciin in her right loin. The pain had come on suddenly while
she was sitting in a chair eating lunch. She had never had the pain
before, and it was severe and persistent. Two hours later she was
admitted to hospital as an 'acute abdomen'.
When the house surgeon saw Mrs Macdonald the pain was still
severe. The patient had felt tired for the previous 2 days but not
feverish. Hypertension had been discovered 16 years before. As
far as her general practitioner was concerned she had been taking
methyldopa ever since, but she readily admitted that she only took
it when she felt unwell. The methyldopa had been restarted 2 days
before admission, after a 3-month gap. For the past year, Mrs
Macdonald had noticed some breathlessness on climbing stairs.
No chest pain had been felt, although she had suffered from an
intermittent central lower back ache for the past few years. Four
years ago her gallbladder had been removed for chronic dyspep
sia secondary to gallstones. She had lived in Jamaica as a child, but
had been in Britain for the past 30 years. Her periods had stopped
3 years ago. She did not go out to work and had four children, the
youngest aged 18.
Mrs Macdonald was a large black lady with a weight of 82 kg.
The pain was making her lie still. Her blood pressure was
150/100 mmHg and her pulse was regular at a rate of 105 beats/
min. She did not appear anaemic. Examination of the abdomen
was hampered by tenderness in the right loin, but no masses could
2
After treatment with oral hydralazine, chlorothiazide and amilo-
ride, the patient's blood pressure fell to 140/95 mmHg over the next
2 days. His temperature rose to 38.1°C the day after admission. He
had no further chest pain, but a sudden deterioration occurred
after 3 days in hospital, when he became semiconscious with a
flaccid right-sided hemiplegia.
Question
What are four possible causes for the hemiplegia and what is the
underlying pathology for each?
Case 2
Mrs Macdonald, aged 54 years, was admitted to the surgical ward
with pciin in her right loin. The pain had come on suddenly while
she was sitting in a chair eating lunch. She had never had the pain
before, and it was severe and persistent. Two hours later she was
admitted to hospital as an 'acute abdomen'.
When the house surgeon saw Mrs Macdonald the pain was still
severe. The patient had felt tired for the previous 2 days but not
feverish. Hypertension had been discovered 16 years before. As
far as her general practitioner was concerned she had been taking
methyldopa ever since, but she readily admitted that she only took
it when she felt unwell. The methyldopa had been restarted 2 days
before admission, after a 3-month gap. For the past year, Mrs
Macdonald had noticed some breathlessness on climbing stairs.
No chest pain had been felt, although she had suffered from an
intermittent central lower back ache for the past few years. Four
years ago her gallbladder had been removed for chronic dyspep
sia secondary to gallstones. She had lived in Jamaica as a child, but
had been in Britain for the past 30 years. Her periods had stopped
3 years ago. She did not go out to work and had four children, the
youngest aged 18.
Mrs Macdonald was a large black lady with a weight of 82 kg.
The pain was making her lie still. Her blood pressure was
150/100 mmHg and her pulse was regular at a rate of 105 beats/
min. She did not appear anaemic. Examination of the abdomen
was hampered by tenderness in the right loin, but no masses could
3
be felt and the bowel sounds were normal. Rectal examination was
unremarkable. The cardiovascular system was normal except for a
systolic, and possibly a diastolic, murmur at the apex of the heart.
The lungs were clear.
After consultation with the registrar, the house surgeon pres
cribed morphine and an antiemetic. The pain was quickly re
lieved. Microscopy of the urine showed some red blood cells but
no organisms. A mild leucocytosis (white blood count 11 300/mm3)
was present. Plain supine and erect abdominal X-rays showed
normal bowel shadows, normal-sized liver, kidneys and spleen;
and no gas under the diaphragm. The chest X-ray and ECG were
normal.
The cardiology registrar was asked for his opinion on the
murmur. He could find nothing abnormal apart from a short
systolic murmur at the apex of the heart followed by a mid-
diastolic murmur with presystolic accentuation. An opening snap
could be heard at the lower left sternal edge. The registrar
performed a 2-D echocardiogram with a rarely used portable
machine. Mrs Macdonald's obesity and inability to lie on her left
side hampered the investigation, but limited views of the anterior
cusp of the mitral valve seemed to show normal movement. He
wondered whether the apparent diastolic murmur could be a third
heart sound. The left atrium was moderately enlarged.
Questions
1. What is the probable cause of the right loin pain?
2. What is the treatment?
Case 3
Heart disease in asymptomatic patients can sometimes create
more problems than similar disease with marked pain or breath-
lessness. Telling somebody who feels fit and well that he or she
has heart disease and then proceeding to treat it may produce
more difficulties than just ignoring the problem. However, some
lesions produce few symptoms until a very late stage, and waiting
for them to appear may be courting disaster.
Mr Jones had felt fine until he had a routine medical examination
as part of an application for a large life insurance policy. A