Our patient presented with rather classic symptoms - crushing substernal chest distress radiating into the arms - and when she arrived in the emergency room, the electrocardiogram showed indicative changes of acute anterior wall infarction. And then we did our bedside examination, at the same time, first in the emergency room and more thoughtfully, yet focused, later and it contributed enormously to our understanding of our patient, because it was an excellent reflector of the extent of the infarction. The two keypoints: the blood pressure and the arterial pulses told us there was likely a low cardiac output; the blood pressure was slightly elevated but there was a narrow pulse pressure and the arterial pulses were hypokinetic, or small, telling us that there was a combination of outporing of catecholamines with a reduced cardiac output. And then, on the remainder of the examination, the most compelling additional finding was listening at the apex, listening at the apex with the bell, where we heard a third heart sound, [sounds] booming home to us the message that there was compromise myocardium, significant amount of muscle tissue that were ischemic. The third heart sound told us that. So, when you combine those two observations you had an index of extent, or severity.
The survival of our patient, we begin by saying, depends upon early diagnosis and the way that is best handled in this era is get to the hospital quickly, emergency number should be called and the patient should be transported as soon as possible to the hospital. It depends upon recongnizing the extent of the infarction and our bedside examination, again, was extremely helpful, and it depends upon instituting therapy early, and that is our intent in our patient.
Course
A summary of our patient's course to this point includes the following key features: her diagnosis is an acute ST-elevation anterior wall myocadial infarction based on her history and the indicative changes see in her initial electrocardiogram; she was treated with oxygen, morphine sulfate, aspirin, heparin, nitroglycerin and beta blockers and blood was drawn for appropriate studies, with the results of cardiac biomarkers of necrosis pending; a focused, but thorough, cardiac examination was carried out in several minutes and was consistent with an extensive infarction; examination of her lungs revealed bibasilar crackles.