A round of Golf

1. Step1: Identifying difficult words and cues

1.1. identify difficult words

1.1.1. Golf course: playground

1.1.2. Solicitor: lawyer

1.1.3. golf cart: car

1.2. identify cues

1.2.1. 70-year-old man

1.2.2. chest discomfort ( clutching at chest) upon walking

1.2.3. " holding onto the golf car for support

1.2.4. calf muscles pain ( more in the right one)

1.2.5. impact on his sport

1.2.6. retired

2. step2: problem formulation

2.1. a retired solicitor in his seventies complaining of chest discomfort upon walking with muscles cramping in his calf .

3. step3: hypothesis generation

3.1. heart disease due to several parameters such as old age

3.2. pulmonary embolism or ischemic heart disease.

3.3. peripheral vascular disease

3.4. anaerobic glycolysis in calf muscles due to compromised perfeusion

3.5. levin's sign ( clutching the hands over the chest) associated with ischemic heart disease

3.6. aortic dissection

4. step4: hypothesis organization

4.1. primary

4.1.1. ischemic heart disease

4.2. secondary

4.2.1. aortic dissection

4.2.2. pulmonary

5. step5: learning objectives.

5.1. 3-to know about the coronary ciculation

5.2. 2-to know the disease that cause chest pain + calf cramp

5.3. 1-to know about ischemic heart disease(cause, risk factors, manifestations,pathophysiology)

6. step6: review

6.1. two major arteries originated from ascending aorta: right and left coronary arteries. most affected vessels are left anterior descending . right and left dominant people.

6.2. peripheral vascular disease

6.3. risk factors for IHD are multiple including: smoking, sedentary life style, alcohol consumption, diabetes, hypertension and dyslipedimia. initially men at a higher risk of CAD than women. however after menopause they are almost equal.

6.4. pathophsyology of CAD: three layers constitutes the vascular wall: tunica intima , tunica media and tunica adventisia. migiration of macrophage in attempt to engulf LDL forming a lipid core. fibrous cab is formed due to proliferiation of the above layers. demand and supply

6.5. the spectrum of CAD starts with asymptmotic state.

6.6. typical presentation includes setrosternal pain radiating to the left shoulder and arm. aggravated by the

7. step7:inquiry plan

7.1. 75-year-old six mounths ago noticed pain in the right calf upon walking feet are always cold 3 months ago chest pain as heaviness compromised his actitvites pain aggravetd during anxiter and stress no chest pain at rest pain during intercourse

7.2. fairly healthy all his life apendectomy 68 told that he had mild attack broken arm winter bronchitis

7.3. physical examination: HR: 82 BP:140/80 RR:14 hight femoral and dorsalis pedis pulse redused with bruit apex beat not reduced crachles heard at the basal of the lungs

8. step8: diagnostic descision

8.1. ischemic heart disease secondary to atherosclerosis.

9. objectives: 1- effect of aging in heart 2- Management IHD

10. Step10: reporting

10.1. vessels compliance decreased endothilial dysfunction and decreased NO reduced COP fibrotic changes in the conducting system

10.2. O2, nitrate, analgesics recurrent use of nitrate may lead to nitrate tolerance. it relieves esophageal spasm right ventricular infarction selpadfile beta blocker contraindicated in asthma and CHF. cessation of beta blocker cause tachycardia calcium channel blocker helpful in coronary spasm vrampili causes bradychardia antiplatalet agents include: aspirin and pras foundaparinxus statin for hyperlipidemia nonpharmacolgical treatment: catheteriztionan smoking cessation excersice diet

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