**PATIENT CASE**

**Patient’s Chief Concerns**
"I’m having pain in my chest and it goes up into my left shoulder and down the inside of my left arm. I’m also having a hard time catching my breath, and I feel somewhat sick to my stomach."

**History of Present Illness**
Mr. W.G. is a 53-year-old man who began to experience chest discomfort while playing tennis with a friend. At first, he attributed his discomfort to the heat and having had a large breakfast. Gradually, however, the discomfort intensified to a crushing sensation in the sternal area, and the pain seemed to spread upward into his neck and lower jaw. The nature of the pain did not change with deep breathing. When Mr. G. complained of feeling nauseated and began rubbing his chest, his tennis partner was concerned that his friend was having a heart attack and called 911 on his cell phone. The patient was transported to the ED of the nearest hospital and arrived within 30 minutes of the onset of chest pain. En route to the hospital, the patient received aspirin (325 mg po) and 2 mg/IV morphine. His pain has eased slightly in the last 15 minutes but is still significant; was 9/10 in severity, now 7/10. In the ED, chest pain was not relieved by 3 SL NTG tablets. He denies chills.

**Past Medical History**
- Ulcerative colitis for 22 years
- Hypertension for 12 years (poorly controlled because of difficulty with adherence)
- Type 2 Diabetes Mellitus for 5 years
- S/P Acute Myocardial Infarction 5 years ago, treated with cardiac catheterization and PTCA; chronic stable angina for the past 4 years
- Benign Prostatic Hyperplasia for 2 years
- Hypertriglyceridemia
- Adenomatous colonic polyps

**Family History**
- Father died from myocardial infarction at age 55, had Diabetes Mellitus
- Mother died from breast cancer at age 79
- Patient has one sister, age 52, who is alive and well, and one brother, age 44, with hypertension
- Grandparents had heart disease

**Social History**
- 40 pack-year history of cigarette smoking
- Married and lives with his wife of 29 years
- Has two grown children with no known medical problems
- Full-time postal worker for 20 years, previously a baker for 8 years
- Occasional alcohol use, averaging 2 beers/week
- Has never used street drugs

**Review of Systems**
Positive for some chest pain with physical activity "on and off for a month or so," but the pain always subsided with rest.

**Allergies**
- Meperidine (rash)
- Trimethoprim-sulfamethoxazole (bright red rash and fever)

**Medications**
- Amlodipine 5 mg po Q AM
- Glyburide 10 mg po Q AM, 5 mg po Q PM
- EC ASA 325 mg po QD
- Gemfibrozil 600 mg po BID
- Sulfasalazine 1.5 g po BID
- Terazosin 1 mg po HS

**Physical/Objective**

**General Appearance**
The patient is an alert and oriented white male who appears to be his stated age. He is anxious and appears to be in severe acute distress.

**Patient Case Questions**

1. Cite six risk factors that predisposed this patient to acute myocardial infarction.

2. Killip classification is used to determine mortality and is based on clinical findings. In which Killip class is this patient’s acute myocardial infarction? What is the prognostic significance of this number? Please provide a citation and explain your answer.

3. Are there any indications that this patient needed oxygen supplementation during his hospital stay? Explain your answer. Provide a citation.