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Clinical Case Study 2


Clinical Case Study in Occupational and Environmental Medicine 

A bus driver with chest pain


At the end of his working shift, a 47 year old bus driver was admitted to the accident and emergency department complaining of worsening severe chest pain and tightness, and shortness of breath. He had a strong family history of ischaemic heart disease (both his father and uncle having had heart attacks before the age of fifty), and he admitted to having smoked since leaving school.

On examination his pulse was 96/minute and he had frequent premature beats, while his blood pressure was 130/70 mm mercury. The electrocardiogram showed ST elevation in the anterior leads. Chest X ray showed slight cardiomegaly and a few 'fine horizontal linear shadows at the bases. Serum enzymes showed elevated creatine kinase and aspartate aminotransferase. 

A diagnosis of myocardial infarction was made, and he was discharged after 12 days with medication to take home as well as instructions to take things easily until review in the outpatient clinic. 
 

Commentary:
  • What would you consider to be the likely management of the patient?
    • Antithrombotic therapy - thrombolysis in the acute stage, perhaps aspirin thereafter
    • Advice on stopping smoking
    • Advice on weight control if overhweight, perhaps lipostatisc agents if indicated by his lipid profile
    • Other cardioprotective measures e.g. beta blockers
    • Advice on graded exercises
    • Further investigations e.g. angiography as a possible prelude to angioplasty maybe...
But is this enough?

What else should be considered?

Think about this ...
then proceed to the next page.

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