NR 603 WEEK 3 CASE STUDY SUMMARY

Running Head: WEEK 3 CASE STUDY SUMMARY Week 3 Case Study Summary Instructor Institution NR 603: Advanced Clinical Diagnosis and Practice Across Life Span Date S: SUBJECTIVE DATA Chief Complaint (CC): CP/SOB 3 days ago. “My wife made me come, I feel fine.” History of present illness (HPI): Chest heaviness, SOB, “sweaty,” nausea, all lasting approx. 3min. None before, none since. Now only feels more tired than normal. “It could be that I have not worked out since it happened.” More energy until episode happened, now concerned because more tired than normal, especially when tries to work out. Not as much strenuous running since episode. Past Medical History (PMH): Overall health reported as good. Chicken pox as a child. H/o HTN, hyperlipidemia; both being managed with lifestyle changes. NKDA. Tonsillectomy, adenoidectomy, cholecystectomy, vasectomy, no h/o blood transfusions. Does not take flu shot. No current medications. Family History (FH): Parents: deceased (Mom: CVA complications; dad: lung cancer). Siblings: brother deceased at 44 (malignant melanoma). Another brother & sister healthy. Social History (SH): Married x20yrs, works as architect. Beer/glass of whiskey/occasional cigar when playing poker with friends. Exercises regularly up until CP 3 days ago. Review of Systems (ROS): constitutional symptoms: no reported fever, unintentional weight loss. + increased fatigue since episode 3 days ago. eyes: no reported eye drainage, itching, tearing, pain. ears, nose, mouth and throat: no reported ear pain/drainage, nasal drainage/congestion, mouth/throat pain. cardiovascular: chest heaviness, SOB 3 days ago, lasting 3min, none since. No reported palpitations or radiation of pain. respiratory: no reported cough, denies congestion/sputum production. SOB 3 days ago during chest heaviness, none since. gastrointestinal: denies heartburn, no reported abd pain. Slight nausea 3 days ago when chest heaviness present, none since. No v/d. genitourinary: no reported urinary symptoms. musculoskeletal: no reported musculoskeletal symptoms. integument: no reported integumentary symptoms other than sweatiness during chest heaviness episode 3 days ago, none since. neurological: no reported neurological symptoms psychiatric: no reported anxiety, depression, excessive stress endocrine: no reported unintentional weight loss/gain, hair loss, skin changes, polydipsia/polyphagia/polyuria. + fatigue as noted above. hematological/lymphatic: no reported bruising/excessive bleeding, lymphadenopathy, recent infections allergic/immunologic: no reported allergies or immunological complaints. O: OBJECTIVE DATA Constitutional: 60-year-old African American male, NAD, A&O, appears stated age, sitting in chair, able to speak in full sentences/answer questions appropriately. Ht 5’8”, Wt 220lbs, BMI 33.5. BP 146/90, P 70, 97% on RA, pain 0/10. HEENT/mouth: Head normocephalic, hair thick/even distribution throughout scalp. Sclera clear, conjunctiva white, PERRLA, EOMs intact bilat, no AV nicking. TMs gray/intact, light reflex noted, pinna/tragus non-tender. Nares patent, no exudate, R-sided deviated septum. Sinuses nontender. Oropharynx moist, no lesions/exudate. Poor dentition, gums reddened/receding, filled cavities noted. Tongue smooth, pink, protrudes midline, no lesions. Neck supple, no cervical lymphadenopathy/tenderness. Thyroid midline/small/firm, no palpable masses. Mild JVD in recumbent position. Cardiovascular: S1/S2 noted, RRR, no murmurs/parasternal lifts/heaves/thrills. Periph pulses equal bilat, no periph edema. PMI 5th ICS displaced 4cm laterally. Respiratory: CTA bilat, resp even/unlabored, no SOB noted. GI: Abd round, soft, bowel sounds noted x4 quads. No organomegaly. Skin: Warm, dry, intact, light brown. No cyanosis/pallor/rashes/vesicles. Neurological: A&O x4, able to answer questions appropriately. Lab/diagnostic testing (3mo ago): TC 230, LDL 180, HDL 38. EKG today: ST depression in II, III, AVF, V3-6. A: ASSESSMENT: Primary diagnosis: Acute coronary syndrome (I25.9) Secondary Diagnosis: hypertension (I10), hyperlipidemia (E78.5), obesity (E66.9), Tobacco use disorder mild (F17.2) Atherosclerotic heart disease (I25.10) disorder of teeth and supporting structures (K08.9). The patient had one episode 3 days ago of chest heaviness lasting 3 minutes, accompanied with SOB, slight nausea, diaphoresis, and fatigue. He has a history of hypertension (managed with lifestyle changes, though BP is elevated today) and high cholesterol (also managed with lifestyle changes, labs from 3mo ago are abnormal). EKG today shows ST depression in leads II, III, AVF, V3-6, indicating some ischemia at some point, but is not enough to definitively diagnose an acute coronary event. He currently has no symptoms except lingering fatigue that is limiting his exercise habits. He cannot definitively by diagnosed with NSTEMI at this time because there are no cardiac enzymes to look at; and he does not fit as well into the diagnosis of angina, since the episode did not appear to occur during activity, nor be relieved by rest; however, since he does have EKG changes, he does need further evaluation as soon as possible, since an acute event cannot be ruled out without further workup (American College of Cardiology, 2017; Amsterdam et al., 2017). Larry has a history of high lipids already, which he has been trying to manage with lifestyle changes; however, since he has had this cardiac event, has ST changes on EKG, BP is still high today, is still fatigued, and has high lipid levels from 3 months ago, he will continue to have the diagnosis of hyperlipidemia and will be started on anti-lipid medications (Jellinger et al., 2017). Larry’s BMI is 33.5, which classifies him as obese; therefore, the diagnosis of obesity fits his condition. If he is compliant with medications, diet, and exercise, his BMI will very likely decrease, which will then decrease his risk of cardiac complications (National Heart, Lung, and Blood Institute, 2013). Larry’s tobacco use is occasional when playing poker, and it is unclear of how often he plays poker as well as it is unclear if his buddies are smoking cigars as well. Tobacco use posed a significant risk for recurrent MI, especially when in combination with hypertension, hyperlipidemia, alcohol use, advanced age, and African American race (Amsterdam et al., 2014). Larry’s teeth are described in the case study as being in poor condition, with receding/reddened gums, and filled cavities. He will need to see a dentist so that his dental health is taken care of. He does not need any further complications, especially since infections can cause strain on the body and therefore the heart. There is a hypothesis that has been studied for many years that indicates periodontal disease can lead to or worsen CVD; pieces of the hypothesis have been proven through various studies, but the overall thought is that it does contribute to cardiovascular complications, so good dental hygiene is essential for Larry in light of his current cardiac condition (Merchant & Virani, 2016). P: PLAN Medications: Larry will need to be given 324mg of ASA (4 chewable tabs of 81mg each) at this time before he is sent to the ER, so that the antiplatelet properties of the ASA can help prevent any further blockages; he will then stay on 81mg daily of ASA, unless his cardiologist recommends a different approach or unless he has to have a higher level of intervention while he is in the hospital, such as PCI (Amsterdam et al., 2014). Depending on what his cardiologist recommends after discharge from the hospital, some minimal possibilities for antihypertensives include amlodipine and chlorthalidone, since his lifestyle management alone has not been successful in getting his blood pressure to an acceptable level (American College of Cardiology, 2017). Additionally, he will need lovastatin to aid in lowering his lipid levels (Jellinger et al., 2017). Aspirin 81mg tab OTC Sig: take one tablet by mouth daily Disp: # 30 (thirty) RF: 0 (Micromedex, 2019) Rationale: will prevent platelet aggregation and exerts an anti-inflammatory effect in the vessels by inhibiting prostaglandin synthesis (Jellinger et al., 2017). Monitor for bleeding, tinnitus, GI irritation. Amlodipine 2.5mg tab Sig: take one tablet by mouth daily Disp: #30 (thirty) RF: 0 (Micromedex, 2019) Rationale: will depress myocardial contractility and increase cardiac blood flow, monitor for arrhythmias and hypotension, there can be occasional worsening of anginal symptoms, may cause ankle edema, and educate that significant drug interaction can occur with grapefruit juice (Jellinger et al., 2017). Chlorthalidone 12.5mg tab Sig: take one tablet by mouth daily Disp: #30 (thirty) RF: 0 (Micromedex, 2019) Rationale: To manage his BP and his higher CVD risk now that he has had some type of coronary event (ACC, 2017). Increases excretion of sodium and chloride thus water, decrease circulation plasma volume. Monitor for hypokalemia, be sure to check potassium level about two weeks after initiation and with an increase in dose, maintain potassium  4 meq/L (Jellinger et al., 2017). Lovastatin 20mg tab Sig: take one tablet by mouth daily Disp: #30 (thirty) RF: 0 (Micromedex, 2019) Rationale: to help lower his lipid levels (Jellinger et al., 2017). Inhibits HHMG-CoA, the enzyme which is partly responsible for cholesterol synthesis. Perform liver function test before initiating therapy, then periodically (Jellinger et al., 2017). Watch for myopathies and advise against grapefruit juice due to possible interaction with medication. Additional diagnostic tests: Labs: Since Larry is going to the ER, he will likely undergo quite a few lab tests, including cardiac enzymes (CK, CKMB, troponin), CBC, CMP, CXR, and BNP. This will help in determining if any/how much damage has been done to the heart, if there are any infectious processes at work, if there is any anemia involved, what electrolyte levels are at, and if HF might be beginning/in process. Serial cardiac enzymes will be done every 4-8 hours to ensure that there has been no elevation or, if elevation is present, to determine how much elevation is occurring and how it progresses or improves (Amsterdam et al., 2014). He should also have lipid levels repeated since it has been three months since the last set, which should give a better picture of where he is at currently; this can help with determining how aggressive lipid-lowering therapy needs to be (Jellinger et al., 2017). Radiography, etc.: Larry will undergo a CXR while in the ER, so basic structures can be visualized and to rule out any other causative or contributing factors (i.e., HF, pneumonia, cardiomegaly, etc.). He will also likely have an echocardiogram done at some point while in the hospital in order to visualize the structures and flow of the heart more closely (Amsterdam et al., 2014). It is highly possible that he could undergo a cardiac catheterization as well, especially if his troponin levels come back elevated or if the repeat EKG (which should happen in the ER immediately) comes back increasingly abnormal. This will assist in actual visualization of any blockages in the vessels in and around the heart, at which time they can be stented if necessary. Serial EKGs need to be performed to see if any changes occur. An exercise tolerance/stress test will likely be performed as well, mainly if cardiac cath is determined unnecessary at this time (Amsterdam et al., 2014). Education: Complete education on ACS definition, risks, outcomes, and Larry’s role in management; All usage instructions, purposes, side effects, adverse reactions, and contraindications to all medications being prescribed, both in the hospital and upon discharge; Importance of continuing lifestyle modifications (i.e., diet, exercise, weight loss, smoking/ETOH cessation etc.) Walking is a great way to get exercise. Eat a heart-healthy diet. Choose foods low in saturated and trans fats and salt. Healthy choices include fish, fruits, vegetables, beans, and whole grains. Quit smoking, and avoid second-hand smoke. Quitting smoking can quickly reduce the risk of another heart attack. Medicines and counseling can help you quit for good, in order to decrease as many modifiable risk factors as possible; How to keep BP log, importance of strict compliance of keeping it accurately, and need for bringing it to each office visit; Importance of strictly adhering to follow-up appointments with primary provider and any referrals that have been made; Importance of flu and pneumococcal vaccinations; Avoid NSAIDs as much as possible, since simultaneous use of ASA and NSAIDs increase risk of internal bleeding complications; Know when to call 911 and when to call office, Wear medical alert bracelet with condition and ASA (or other antiplatelets that might have been prescribed) listed; Keep current copy of all medical diagnoses, surgeries, medications, allergies in wallet, on phone, or in shirt/pants pocket at all times, along with emergency contact information (Amsterdam et al., 2014). Activity: Be active, start slowly, and controlled at all time. Try parking farther away from the store or walk the mall before shopping. Over time, you will increase your ability to do more. Keep a record of your daily exercise. It is okay to skip a day occasionally or to cut back on your exercise if you are too tired or not feeling well. Active 30 minutes a day, at least five days a week. It is okay to be active in blocks of 10 minutes or more throughout your day and week. Pace yourself by alternating exercises. Rotate light workouts, such as short walks, with more strenuous exercises, such as low-impact aerobics or swimming. Avoid exercising outdoors in extreme temperatures or high humidity or poor air quality. When the weather is bad, try exercising indoors at a gym or walking at a mall. Avoid exercises that require or encourage holding your breath, such as push-ups, sit-ups, and isometric exercises. Also, avoid heavy lifting. If you develop palpitations, angina symptoms, difficulty breathing, or dizziness or light-headedness, stop exercising and rest. Call the office and let us know even if the symptoms go away, we need to know that way we can adjust the level of activity. Do not take hot or cold showers or sauna baths after exercising. Take your pulse frequently or wear a heart rate monitor and record in your blood pressure log. Watch your pulse when walking up hills or stairs. Gradually increase to your regular activity level as tolerated. Stay with it, understand that it is hard to stay on an exercise program but making it fun and enjoyable will help you adhere to an active lifestyle. American Heart Association (2018), being inactive and sitting too much with a higher risk of heart disease, type 2 diabetes, colon, and lung cancers and early death. Being active stands for a better quality of life and sense of overall well-being. Follow up: In clinic (and with cardiology) at least one week after discharge from hospital (whether admitted inpatient or not) to re-evaluate Larry’s condition and make sure that he is progressing positively). The follow-up will include medication reconciliation, review of symptoms, an updated cardiovascular risk assessment, psychological status to monitor for depression and anxiety, evaluation of changes in his activity, and the compliance on the established plan. Larry should be able to verbalize his medication regimen, his current diet, current exercise routine, and voice any symptoms he has been experiencing since discharge. Then again one month after starting antihypertensive therapies to re-evaluate overall status and BP logs/goals (Amsterdam et al., 2014). Lipid levels need to be redrawn 12 weeks after starting lovastatin, then every 6-12months after lipid levels have stabilized (Jellinger et al., 2017). Referrals: Emergency room from the primary clinic, for an ambulance and send Larry to the nearest ER for further evaluation and possible admission (ACC, 2017). Cardiology so that his cardiac condition can be closely monitored and managed long-term with possible cardiac rehab (ACC, 2017; Amsterdam et al., 2014). Dentist so that his poor dentition can be managed. Dietitian for assistance in managing his diet so that modifiable risk factors due to a poor diet can be decreased (Amsterdam et al., 2014). References American College of Cardiology. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force clinical practice guidelines. The Journal of the American College of Cardiology. doi: 10.1016/.2017.11.006 American Heart Association (2018). Recommendations for Physical Activity in Adults and Kids. Retrieved from: Amsterdam, E.A., Wenger, N.K., Brindis, R.G., Casey, D.E., Ganiats, T.G., Holmes, D.R… Zieman, S.J. (2014). 2014 AHA/ACC guideline for the management of patients with non- st-elevation acute coronary syndromes. The Journal of the American College of Cardiology, 64(24), e139-e228. Doi: 10.1016/.2014.09.017 Jellinger, P.S., Handelsman, Y., Rosenblit, P.D., Bloomgarden, Z.T., Fonseca, V.A., Garber, A.J… Davidson, M. (2017). American Association of Clinical Endocrinologists and American College of Endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease. Endocrine Practice, 23(Suppl. 2), 1-87. Retrieved from Merchant, A. & Virani, S.S. (2016). Periodontal health and cardiovascular disease risk: Association or causation? Retrieved from cardiology/articles/2016/08/15/13/38/periodontal-health-and-cardiovascular-disease-risk Micromedex. (2019). IBM Micromedex Retrieved from https://www-micromedexsolutions- National Heart, Lung, and Blood Institute. (2013). Managing overweight and obesity in adults. Retrieved from