The Patient’s Story
John Stanton is a 66 year old man brought in by the emergency medical technicians after his daughter Karen dialed 911. Mr. Stanton was in the yard playing with his grandsons when he suddenly fell down in a faint and his daughter who was watching him through the window called 911. His grandsons reported that Mr. Stanton had complained of chest tightness and then fainted. In the hospital he was noted to be hypotensive secondary to a urosepsis. The hypotensive episode precipitated a small myocardial infarction and he ruled in with an elevated troponin. He was hospitalized and stabilized. He is a new patient to your health care system and has historically never seen a doctor. You are told that he does not trust or believe in the medical system after his wife Marie died 5 years ago due to metastatic colon cancer.
Past Medical History
He has always hated hospitals and refused to see the doctor. His dislike for hospitals and physicians was further reinforced by the sudden and unexpected death of his wife.
He was told that he had high blood pressure and high cholesterol at a health fair many years ago, but refused to “let quacks mess with my body”. His diet is heavy on red meat, potatoes, and fatty foods and low in fruits, vegetables and whole grains.
He had been experiencing moderate to severe chest tightness and breathlessness several weeks prior to admission, but he has kept quiet about it since he did not want to stress out Karen, his pregnant daughter. Last Wednesday evening, he was playing ball and running after his young grandsons when he suddenly experienced chest tightness and had a blackout. His daughter called 911 and admitted him to the hospital.
At the ER the patient was ruled in for an MI with acute ST-T changes and a troponin of 12. He was found to be hypotensive. Fortunately he responded to fluid boluses and has not required any pressors. Per ER doc, the patient has adamantly refused to go to the ICU and does not want any heroic life prolonging measures. He would prefer to go home as soon as possible. He is documented to be surly and hostile. He is accompanied by his pregnant daughter Karen (he lives alone in the townhome next to hers).
Cardiology was consulted and felt that patient had a silent, recent and evolving MI, perhaps a week prior to admission. The cardiac echo revealed decreased LV function with an estimated ejection fraction of 20% and severely thickened and or calcified, and severely stenotic Aortic Valve (is 0.4 cm squared with a mean gradient of 35 mm Hg)
Cardiologists want to do a cathetization for further evaluation but the patient refuses.