Erica Stuchell

Case Study 18A

10/28/13

Mr. X., aged 55 years, arrives at the emergency department with severe chest pain. He appears very anxious, and his facial skin is cool and clammy. His blood pressure is 90/60, and his pulse around 90, weak, and irregular. He is given oxygen, an intravenous line is opened, and leads for ECG are attached. Blood is taken for determination of serum enzymes and electrolytes. Tentative diagnosis is myocardial infarction involving the left ventricle. His wife arrives and, in response to questions, indicates that her husband is a heavy cigarette smoker, prefers a diet of fried foods and meat (he is obese), and had complained periodically of indigestion, with brief episodes of epigastric pain. He also seemed to be more fatigued at night recently but was very busy at work. He was fearful of heart disease because his father had died of a heart attack. He had also noticed more fatigue and intermittent leg pain when playing golf recently. Generalized atherosclerosis is suspected. 1. List the high-risk factors for atherosclerosis in this patient's history. The high-risk factors for the atherosclerosis in the patients history include smoking, obesity, and a diet high in cholesterol and fat, family history of heart disease and heart attack. 2. Describe how atherosclerosis causes myocardial infarction. Atherosclerosis causes myocardial infarction by causing an excessive buildup of plaque occurring over time. Development of a fatty streaks, low density lipoproteins adhere, MACs engulf the LDLs, smooth muscle infiltrates, fibroblasts produce a collagen cap, and finally, the cap tears and forms a lesion, forming a clot and finishing with the closure of the lumen. 3. It is suspected that the indigestion reported in the history was really angina. Explain how this pain may have occurred. Chest pain is something many people write off as indigestion when in fact it closely mirrors what is really Angina. Angina is a chest pain resulting from a reduced blood flow to the heart. Your heart is deprived of oxygen because of a coronary artery disease like angina, you will experience tightness, pain, and pressure in your chest. In angina there is no permanent damage done to the heart muscle, but when the interruption occurs the myocardium of the heart starts to die also known as a heart attack. 4. Explain why Mr. X. had a rapid but weak pulse on admission. Typically a rapid but weakened pulse is caused by decreased circulation combined with tachycardia. Tachycardia is when the heart is beating too fast and occurs during arrhythmia. A cardiac arrhythmia weakens the pulse and presents with cool and clammy skin such as patient X had. The patient was most likely entering a stage of shock due to the prolonged exposer and not recognizing the symptoms right away. Patients who have arteriosclerosis will present with a pulse that is weakened in the external limbs, all classic sign for a myocardial infarction.

Erica Stuchell 5. Explain each of the admitting signs.

Case Study 18A

10/28/13

Severe chest pain is a major indicator of MI, caused by a complete blockage of one of the coronary arteries. The muscle supplied by that artery becomes oxygen starved. Anxious feelings occur because, much like an anxiety attack your body is being deprived of oxygen rich blood and speeds up also releasing hormones and his facial skin is cool and clammy because of the bodys response to the rapid heart rate is to start sweating. Much like while exercising, you break a sweat to release the excess body heat and if you have ever noticed that you are actually cool to the touch just after running a few miles, this is the same type of response that occurs after a heart attack, and possibly when shock develops. 6. Why are serum enzymes and electrolyte levels important? Serum levels of myosin and cardiac troponin are elevated a few hours after MI and will provide confirmation of an earlier problem. Serum enzymes typically only show up when cells are damaged. The elevation levels of the enzymes will determine the amount of tissue damage to the area, determining if the patient has suffered a heart attack. Electrolyte levels include sodium, potassium, chloride, and bicarbonate. Low sodium concentration is found when a patient presents with congestive heart failure. Potassium regulates the heart beat and heart muscle function. A profound decrease of potassium can increase the chance of an arrhythmia be present and be can prove to be fatal. Chloride controls the normal balances of fluids in the body and high levels can be fatal. Bicarbonate ions control the levels of acidity in the blood and abnormal levels can interfere with respiratory functions 7. What purpose does the ECG serve? An ECG is the initial diagnosis method for monitoring cardiac problems. Its a noninvasive procedure that illustrates the electric activity of the heart as well as systemic abnormalities such as serum electrolyte imbalances. ECGs monitor the electrical activity of the SA and AV node; which causes the muscle in the atria and ventricles to contract. It gives a picture of the pronounced Q waves and ST elevations. The waves viewed in an ECG are the P, QRS, and T waves. The P wave is your atrial contraction, QRS wave is ventricular contraction, and T wave is what happens during repolarization or when ventricles are recharging for the next contraction.

Erica Stuchell

Case Study 18A

10/28/13

It is determined that Mr. X. has a large infarct in the anterior left ventricle. 8. Mr. X. is showing increasing PVC's (premature ventricular contractions) on the ECG. State the cause and describe the effect if they continue to increase in frequency. PVC or premature ventricular contraction, are premature heartbeats arising from the ventricular muscle cells of the heart and come before the actual heartbeat. After a PVC, the electrical system of the heart resets causing a pause in the beat. The main causes are lack of oxygen to the heart, sometimes its a heart attack, high blood pressure, or electrolyte imbalances. If PVCs continue to increase infrequency the patient could end up with a decreased cardiac output. As it progresses to multiple locations ventricular fibrillation will develop, which results in neither the SA nor AV node firing and throws the patient into cardiac arrest. 9. Explain why Mr. X. is at risk of venous thrombosis. Mr. X has had a Myocardial Infarction, with a suspected angina. This can result in a thrombus developing over the infarcted location. Eventually this Thrombus will break off inside the heart and travel through the body possibly to the brain or another location. Pairing this with the lower leg pain that is already present it puts him at a higher risk for venous thrombosis that can also result in a pulmonary embolism. 10. Describe how Mr. X's heart will heal and how its function is likely to be affected. After MI the heart creates scar tissue at the sight of the infarction mainly from the heart being deprived of oxygen. When blood flow is restored to the heart white blood corpuscles go the site of the damage and remove dead cells and thus the scar tissue forms inside the heart wall. Since scar tissue cannot contract like normal tissue this adds pressure to the heart. Depending on the size of the blockage and the amount of scar tissue present determines overall blockage. This scar tissue also can interfere with the electrical rhythm, and cause a permanent arrhythmia. 11. Blood test show hyperlipidemia with high LDL levels. Estimate the risk of recurrence of myocardial infarction based on these levels. Hyperlipidemia is defined as an excessive amount of lipids in the blood. Low density proteins (LDL) are your lipoproteins in the blood which are the fat protein complexes. A high amount of LDLs puts a person at greater risk of heart attacks. Patient X has very high risk of another MI. unless he changes his diet, lifestyle, and takes the medication to reduce his LDL levels. 12. Suggest several measures that can reduce the risk of recurrence. Some things that will help Patient X to reduce the chance of reoccurrence would be to quit smoking, decrease his intake of fried and fatty foods, reduce the amount of red meat, try to lose some weight with a regular exercise routine, and taking medication will all help his overall life and the chances of a second MI.

Erica Stuchell

Case Study 18A

10/28/13

13. Mr. X. is at risk of congestive heart failure. List the significant signs of this if it develops. Symptoms of congestive heart failure are fatigue, edema of the abdomen, legs, ankles, shortness of breath, difficulty breathing during sleep, and increased urination.

During Mr. X's recovery, extensive tests are administered. They show generalized atherosclerosis, including lesions in the abdominal aorta and iliac arteries.

14. How are these legions probably connected to the fatigue and leg pain experienced while playing golf? Atherosclerosis is a the thickening of the artery walls that causes reduced blood flow that results in poor circulation. This can be connected to the fatigue and leg pain Mr. X experienced while playing golf. 15. Suggest some precautions in regard to foot care that Mr. X can take. Mr. X should wear compression stockings to reduce swelling and elevation of his feet will take pressure off. When blood flow to the lower extremities is decreased, delayed healing of sores, serious infections, and gangrene of the feet or toes can occur after seemingly minor injuries. Its important to look at your feet daily, inspect them and take extra precautions.