It is scary

What is a stenosis that seems scary

Ive just read it i dont understand most of it. Who wrote that? All those medical terms i understand tue basics from what you told me but cant follow this at all if I didnt know what happened.

Ok sounds good, second eye check doesnt hurt

心臟科多專科團隊（MDT）討論摘要 病人基本資料 71 歲男性。 既往病史： • 2013 年 NSTEMI（非 ST 段上升型心肌梗塞），接受 PCI 並置放兩支冠狀動脈支架。 • 已知多支冠狀動脈疾病（Multivessel Coronary Artery Disease）。 • 第二型糖尿病。 • 高膽固醇血症。 • 近數月因嚴重坐骨神經痛活動量明顯下降，期間因止痛藥治療，心臟藥物服用依從性亦有所下降。 病史背景 2013 年心肌梗塞後冠狀動脈攝影顯示多支血管病變，PCI 後仍殘留部分冠狀動脈狹窄，之後多年整體病情相對穩定。 本次病程 近數日開始反覆胸痛，其最顯著的特徵為症狀幾乎都在進食後出現，並伴隨： • 劇烈胸骨後及上腹（心窩部）疼痛。 • 心窩部明顯隆起，觸診非常堅硬（家屬形容「硬得像骨頭」）。 • 持續數小時（最長約八小時）的打嗝。 • 噁心，但完全無法嘔吐。 • 不斷打嗝、嗝氣（belching），可稍微減輕疼痛。 上述症狀與進食具有高度一致的關聯性。 第一次住院（週三至週五） 因胸痛至醫院就診。 當時檢查結果： • 初始 ECG 無明顯異常。 • Troponin 升高。 • 血流動力學穩定。 院方認為主要診斷為可能的胃食道逆流（GORD），合併穩定／不穩定型心絞痛，因此： • 增加 Omeprazole 劑量。 • 新增 Isosorbide Mononitrate。 • 增加 Bisoprolol 劑量。 • 安排門診胃鏡（OGD）。 • 建議 GP 若症狀持續，轉介 Angina Clinic。 病人接受此診斷，是因為住院期間早餐後即曾出現最嚴重的一次疼痛，因此認為與消化系統有關。 出院後病情惡化 返家後持續出現： • 餐後劇烈疼痛。 • 長時間打嗝。 • 心窩部持續膨脹且堅硬。 • 想吐卻無法嘔吐。 • 頻繁嗝氣。 至星期日晚間約 21:00 起，症狀明顯改變： • 劇烈中央胸痛。 • 疼痛放射至左肩及左上臂。 • 放射至頸部。 • 放射至背部。 疼痛整夜持續，約凌晨 03:00 達到高峰，病人整夜無法入睡。 急性 STEMI 星期一救護車到場後，救護員立即依 ECG 判斷為急性 STEMI。 送往心導管室前與心臟科醫師交班時提到： • V3-V4 ST elevation 約 3 mm。 • II、III、aVF 約 1 mm ST elevation。 • aVL、V1、V2 T-wave inversion。 • 無 pathological Q waves。 病人立即以藍燈送往心導管室。 冠狀動脈攝影結果 PCI 顯示： • 一條位於心臟後壁供血的冠狀動脈完全阻塞（100%），已成功置放支架。 家屬之後被告知： • 其他冠狀動脈仍存在嚴重狹窄，約達 90%。 目前治療計畫為： • 先以最佳藥物治療控制。 • 再重新評估殘餘狹窄程度。 • 若狹窄仍嚴重，將考慮再次 PCI 放置支架。 目前狀況 • 心臟超音波已完成，正式報告等待主治醫師判讀。 • 血壓持續偏低（約 100–108 / 65 mmHg）。 • 因低血壓，目前已有一項心臟藥物暫停使用。 • 糖尿病控制穩定。 希望 MDT 協助討論的重點 家屬完全接受此次已明確診斷為急性心肌梗塞。 然而，仍希望釐清本次明顯且持續數日的消化道症狀是否能完全以心肌梗塞解釋。 主要問題如下： 1. 最初的症狀是否其實就是持續惡化中的心肌缺血／不穩定型心絞痛，最後進展為 STEMI？ 2. 是否同時存在另一項上消化道疾病，誘發、加重或掩蓋了心臟缺血症狀？ 家屬特別擔心以下症狀並非典型心肌梗塞即可完全解釋： • 症狀幾乎固定於餐後發生。 • 心窩部明顯且非常堅硬的膨脹。 • 持續數小時的打嗝。 • 噁心但完全無法嘔吐。 • 嗝氣可部分改善疼痛。 雖然急性心肌梗塞確實可能出現噁心、上腹痛及其他自主神經症狀，但上述症狀早於 STEMI 數日前即已出現，且與進食高度相關，因此家屬擔心可能存在獨立的上消化道病變。 希望 MDT 協助評估： • 是否仍建議依原計畫完成 OGD（胃鏡）及消化系統檢查？ • 是否存在其他上消化道疾病，可解釋餐後腹脹、頑固性打嗝及無法嘔吐等症狀？ • 是否可能有胃腸道疾病與冠狀動脈缺血同時存在，甚至影響了最初的臨床判斷？ 家屬最大的希望，是在目前心臟問題獲得治療的同時，不要忽略可能仍存在且尚未診斷的消化系統疾病。

Clinical Summary for MDT Discussion Patient: 71-year-old gentleman with: • Previous NSTEMI (2013) treated with PCI and two coronary stents. • Known multivessel coronary artery disease. • Type 2 diabetes mellitus. • Hypercholesterolaemia. • Recent significant reduction in mobility due to severe sciatica, with reduced adherence to his usual cardiac medication while taking analgesics. Background Following his 2013 NSTEMI, angiography demonstrated multivessel coronary artery disease with residual coronary lesions after PCI. He has remained generally well since then. Current Presentation He developed recurrent episodes of chest pain over several days. A striking feature was that the pain consistently occurred after eating and was associated with: • Severe epigastric/retrosternal pain. • Marked upper abdominal ("solar plexus") distension which became extremely firm to palpation ("hard as bone" according to family). • Prolonged hiccups lasting up to approximately 8 hours. • Nausea without the ability to vomit. • Repeated belching which provided partial symptomatic relief. The post-prandial nature of the symptoms was very consistent. First Admission (Wednesday-Friday) He attended hospital with chest pain. Findings included: • Initial ECG reportedly normal. • Troponin elevated. • Haemodynamically stable. He was discharged with a working diagnosis of likely GORD together with stable/unstable angina. Management included: • Increased omeprazole. • Commencement of isosorbide mononitrate. • Increased bisoprolol. • Planned outpatient OGD. • Advice for GP review and angina clinic referral if symptoms persisted. He accepted the gastrointestinal explanation because he experienced one of his worst episodes after breakfast whilst still an inpatient. Subsequent Deterioration Following discharge, he continued to experience: • Severe post-prandial pain. • Prolonged hiccups. • Persistent upper abdominal distension. • Inability to vomit. • Frequent belching. On Sunday evening (approximately 21:00), the clinical picture changed significantly. He developed: • Severe central chest pain. • Radiation into the left arm. • Radiation into the neck. • Radiation into the back. Pain continued throughout the night, peaking at approximately 03:00, and he remained awake because of the severity. Acute STEMI Ambulance attended Monday morning. The attending paramedics immediately diagnosed an acute STEMI from the ECG and transferred him directly to the cardiac catheter laboratory. The paramedic handover to cardiology described: • 3 mm ST elevation in V3-V4. • Additional ST elevation in II, III and aVF. • T-wave inversion in aVL, V1 and V2. • No pathological Q waves. Coronary Angiography PCI demonstrated: • One coronary artery ("at the back") completely (100%) occluded. • Successful stent placement. The family have subsequently been informed that additional coronary arteries remain significantly diseased (reported as up to approximately 90% stenosis). Current plan appears to be: • Optimisation of medical therapy. • Reassessment of residual stenoses. • Further PCI if medical treatment does not sufficiently improve the remaining lesions. Current Status • Echocardiogram has been completed. • Consultant review of the echocardiogram is awaited. • Blood pressure remains relatively low (approximately 100-108/65 mmHg). • One cardiac medication has reportedly been withheld because of hypotension. • Diabetes has remained stable throughout admission. Key Clinical Question The family fully accept that he suffered an acute myocardial infarction. However, they remain concerned that the prominent gastrointestinal symptoms may not have been fully explained by the cardiac event. Specifically: • Was the initial presentation primarily unstable coronary ischaemia with atypical symptoms that progressed to STEMI? • Or is there concurrent upper gastrointestinal pathology that either precipitated or masked the cardiac symptoms? The family are particularly concerned by the following features, which seem difficult to attribute solely to myocardial infarction: • Consistent post-prandial onset. • Marked firm epigastric distension. • Prolonged hiccups (up to 8 hours). • Nausea with inability to vomit. • Belching providing partial relief. Although autonomic gastrointestinal symptoms are recognised during myocardial infarction, these symptoms appeared particularly prominent, reproducible after meals, and began several days before the confirmed STEMI. Request to MDT The family would be grateful if the MDT could specifically consider whether the gastrointestinal presentation requires independent investigation rather than being assumed to have been entirely secondary to the myocardial infarction. In particular: • Should the planned OGD and gastrointestinal work-up still proceed? • Is there another upper gastrointestinal diagnosis that could explain the abdominal distension, prolonged hiccups and meal-related symptoms? • Could concurrent gastrointestinal pathology have contributed to, precipitated, or obscured recognition of worsening myocardial ischaemia? The family are keen to ensure that the gastrointestinal component of his presentation is not overlooked now that the cardiac diagnosis has been established.

Gloria has a friend who is some sort of senior doctor in Taiwan so we are sending this

Wine flu

Hahaha

No really

🇲🇰

Fala mnogu x

Aha 😤 😂

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I have flu tho

Sorry don’t need to answer just checking from tablet what it will be like video I can’t set it properly

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Ok

But I’m not Not Sure that’s what you really want to achieve

There is a way you can do it either from the tablet or the phone and use it on the big screen

Yes, but

Hi Hatty I’m feeling really poorly since yesterday, waiting for the gp to call me back and don’t know when it’s going to be. Not really in any shape to work today at all. Would you mind if I came tomorrow instead?

I dont know how to connect the tablet to the screens though any ideas?

Fala. Xx

Let’s talk about the morning routine another time. Today is an important day and I don’t want you worrying about any of that before your interview. Good luck — I really hope it goes well. xx

I wasnt up at 6 today i got up at 7 cause i was up till midnight. I got ready yesterday and took her on time fine. I can do it but its just fair and nice if you can help too.and be on time. If i didn't have to make your coffee i would have sorted annas toy so she isnt upset and there wouldnt have been pressure. I had her ready in time otherwise. But shes been upset all morning i had to sit with her for 20min so couldnt go in shower. Its the change to school she is upset that she cant play with me during the week. I said daddy can play she says I dont want he is being silly with my games, he says I cant help it. I know its funny for you that but for her its annoying. She has Jessica telling her all the time what to do, we need at home to play by her rules at least. Anyway I was gonna tell you that earlier but forgot. We really need to start being earlier in morning, im guilty of that too, its causing so much tension and anxiety in me and her.

I thought I charged my gone shsh

Call me at 6

Def going

I was fall.qsleep.wo5h harrynwoke up with james bay hhah

Me too

In bed gonna sleep

Night night, let’s talk tomorrow

Noo just about to go to sleep too

Time for me to sleep now I hope you’re not up too late Night night

Yes

I’m glad and Suzana needs some good news

Yeahs...

Fell shotty :(

Ohh

I am and I think Suzana is

:(

So its my fault tho

Yup

Thank you for the transcript. Are you completely reassured now

True