The hospital in an ambulance

The hospital in an ambulance

A 52-year-old insurance adjuster is brought to the hospital in an ambulance. His wife, who accompanied him, stated that during dinner he started to complain of excruciating chest pain in the region of the sternum. These symptoms were accompanied by nausea, vomiting, and severe shortness of breath. She also pointed out that for several years the patient had been suffering from chest pain that radiated into the left arm, particularly after physical effort or emotional upsets.
Examination
      On admission the patient appears in shock. His skin is ashen gray with some cyanosis (bluish tinge), and is cold and clammy. His blood pressure is low, his pulse is quite weak, and his pulse rate is 110 per minute. His respirations are noisy and gasping. On auscultation of the lungs, abnormal breaths sounds are heard. His heart sounds are feebly and arrhythmic. In spite of oxygen application, intravenous injection of circulatory stimulants, electric defibrillation and terminal cardiac massage, the patient expires within two hours of admission. At autopsy there is found marked narrowing of both coronary arteries and many of their branches, due to atherosclerosis of the vessel wall. There is an old occlusion in the first portion of the right coronary artery and a fresh intimal hemorrhage in the anterior interventricular branch near its origin from the left coronary artery. This, in combination with a fresh blood clot, has completely occluded the anterior interventricular branch.