Download Mr John who is an obese 47 years old businessman

Integrated Teaching Area (ITA) Scenarios for Semester One
Week 4
Introduction
Four clinical scenarios relating to chest pains are given below. These will form the basis for the ITA sessions at
Ninewells in Week 4.
To help you prepare the background for these ITA sessions, you should:
1. Prepare answers to the Structured Tutorial questions below (Page 4). Take your answers to the meeting
with your tutor in Week 3. At these tutorials, there will be a group discussion about the questions.
2. Meet in your small groups to discuss the topics listed under “Small Group Work” below (Page 5).
At the ITA sessions, further questions will be set, and additional material will be available in the ITA to help you
better understand the relationship between the basic principles and the patient scenarios.
Scenario 1:
John is 47 years old; he is 1.75 meter tall and he weighs 98 kg. He owns a printing company employing seven
people. John inherited the printing company from his father who died suddenly of a heart attack in 1995. John is
married to Mary. Mary is 42 years old and works as a part-time receptionist at a local dental clinic. The couple
have three teenage children, a boy and two girls. John works about 90 hours per week and rarely sees his wife
and children. His company ran into financial difficulties and he worries incessantly about balancing the books.
John smokes 40 cigarettes per day since his teens. He attends frequent business dinners during which he enjoys a
few drinks. In an average week he consumes about 3 bottles of wine, 14 pints of beer and another seven double
whisky. Mary and the kids are members of a local fitness club, but John doesn’t have time to join them.
Four years ago, during a routine visit to his doctor, John was told that his blood pressure was high at 175/110. His
doctor advised him to change his life style and reduce his weight. John’s blood pressure remained high at around
170/100 on several subsequent visits to his doctor. He was then prescribed some tablets to lower blood pressure;
nevertheless, he often forgets to take them.
John woke-up in the early hours of one morning complaining of severe crushing central chest pain. The pain
radiates to his left arm. He became sick, vomiting twice, and he was sweating profusely. The pain lasted for more
1
than 30 minutes during which time Mary became really worried and decided to call for an ambulance. John was
taken to Ninewells Hospital.
Scenario 2:
Ann is 58 years old. She has been troubled with osteoarthritis and joint pain for the last 20 years. Seven years
ago, following the death of her husband from lung cancer, Ann took early retirement from her work as a secretary
in a local firm. Four years ago, her two grown-up sons moved to work in London, and Ann has been living alone
since then. Two years ago, Ann started to experience severe pain affecting her left knee. The medications
prescribed by her doctor were not helping much; and he decided to send her to Ninewells hospital to see the
orthopaedic surgeon. The orthopaedic surgeon offered Ann surgery to replace her left knee putting her name on
the waiting list. For the last nine months, Ann was unable to walk to the local shops. She has been receiving help
from a neighbour since then. At last, Ann had the knee-replacement surgery 6 weeks ago. Everything seemed to
have gone very well and Ann was recovering well at home.
Yesterday, Ann was brought by an ambulance to the Accident and Emergency Department at Ninewells
complaining of severe pain on the right side of her chest and shortness of breath. The pain was sharp and made
worse by taking a deep breath and by movement. Approximately one hour prior to her admission, Ann coughedup a small amount of blood. She denied any fever or chills. Two days prior to her admission, Ann developed mild
pain in the right leg associated with swelling & redness especially at the back of the leg below the knee. The leg
pain seemed to be made worse by bending the foot upward towards the knee. Ann thought the leg pain was
unimportant, attributing it to muscle strain. She denied any personal or family history of blood clots.
Scenario 3:
Jane is 34 years old. She works as a nurse in the children wards at Ninewells hospital. Jane lives in a first floor
flat with her boy friend Andrew, who works in a local supermarket. For the last 6 months, Jane became
progressively short of breath particularly on climbing stairs at work. She always felt tired and she eventually
stopped playing tennis with Andrew on Sundays as she used to do. Jane at first attributed her symptoms to lack of
fitness, but the breathing problem seemed to be worsening. Eventually, she found it difficult even climbing stairs
to her first-floor flat. Jane also felt a racing and erratic heart beat, and chest pain. She was worried that she may
have something wrong with her heart especially after watching a TV programme about blocked coronary arteries
and heart attacks. Jane then went to see her doctor. During the consultation, she recalled that she had rheumatic
2
fever at the age of 9. Her doctor listened to her heart with a stethoscope and found a murmur. Following a series
of investigations at Ninewells Hospital Jane was told that her symptoms are caused by a leaking atrio-ventricular
valve on the left side of the heart; and that the chest pain was secondary to the racing erratic heart beat. She has
been prescribed some medications and now feels better.
Scenario 4:
Rob is 61 years old. Rob has known for more than 3 years that he has high blood pressure and an aneurysm of his
thoracic aorta. This was discovered incidentally when Rob was investigated for a medical problem. When first
diagnosed, the aortic aneurysm was not giving Rob any symptoms; nevertheless, Rob was advised to come to the
hospital for regular follow-up to check his blood pressure and assess the size of the aneurysm. At first Rob
complied with advice, but then felt that the follow-up may not be as important as the doctor has indicated. Rob
was lost for follow-up for the last 18 months.
Last night while watching TV with his wife, Rob developed a sudden onset severe central chest and upper back
pain. The pain was tearing and ripping in character. His wife phoned for an ambulance and he was taken to
Ninewells Hospital. Rob had urgent surgery, but sadly died in the operating theatre.
3
Structured Tutorial Questions Week 3
(Linked to ITA Week 4: Chest Pain 1 Scenarios)

Estimate the number of weekly units of alcohol consumed by John (scenario 1). How does John’s alcohol
intake relate to UK guidelines for alcohol intake?

What can you deduce from John’s height and weight measurements (scenario 1)

What route does a red blood cell take round the body from and back to your left big toe? (relevant to all
scenarios)

What is the aorta? What pressures does the aorta normally have to withstand? What structures in the wall
of the aorta enable it to withstand these pressures? (scenario 4)

What is (i) an atheroma and (ii) a thrombus? What effects will these have on the circulation of a red blood
cell? (relevant to all scenarios)
4
Small Group Work Prior to ITA Session: Week 3
(Linked to ITA Week 4: Chest Pain 1 Scenarios)

What advice would you offer to John to improve his life style? (scenario 1)

How the heart muscle is supplied by blood? (scenario 1 & 3)

Discuss the range of investigations available to doctors to investigate heart disease? (relevant to all
scenarios)

How many valves are there in the heart? (scenario 3)

What is role of valves in the heart? (scenario 3)

What is the name of the atrio-ventricular valve on the left side of the heart? (scenario 3)

What makes the heart beat at a steady rhythm in a normal person? (scenario 3)

Discuss why people are concerned about deep vein thrombosis (DVT) in relation to long distance flights?

What puts some people at an increased risk of developing DVT? (scenario 2)
5