ACUTE CORONARY SYND
ROME (ACS)
MYOCARDIAL INFARCTION (MI)CASE STUDY.
Acute Coronary Syndrome/Acute MI
History of Present Problem:
JoAnn Smith is a 68-year-old woman who presents to the emergency department
(ED) after having three days of
progressive weakness. She denies chest pain but admits to shortness of breath
(SOB) that increases with activity. She also
has epigastric pain with nausea that has been intermittent for 20-30 minutes over
the last three days. She reports that her
epigastric pain has gotten worse and is now radiating into her neck. Her husband
called 9-1-1 and she was transported to
the hospital by emergency medical services (EMS).
Personal/Social History:
JoAnn is a recently retired math teacher who continues to substitute teach part-
time. She is physically active and lives
independently with her spouse in her own home. She has smoked 1 pack per day
the past 40 years. JoAnn appears anxious
and immediately asks repeatedly for her husband upon arrival.
What data from the histories are RELEVANT and have clinical significance to
the nurse?
Patient been having left sided weakness for three days, shortness of breath
increases with activity, denies chest pain, she also has epigastric pain with
nausea that has been intermittent for 2o-30 minutes over the last three days
epigastric pain has gotten worse now radiating into her neck and she also
feels anxious and she smokes one pack per day for the past 40 years
These signs and symptoms are related to a coronary artery disease and
she could be having a heart attack
[Date]
, Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment
(5th VS):
T: 99.2 F/37.3 C (oral) Provoking/Palliative: Nothing/Nothing
P: 128 (regular) Quality: Ache
[Date]
ROME (ACS)
MYOCARDIAL INFARCTION (MI)CASE STUDY.
Acute Coronary Syndrome/Acute MI
History of Present Problem:
JoAnn Smith is a 68-year-old woman who presents to the emergency department
(ED) after having three days of
progressive weakness. She denies chest pain but admits to shortness of breath
(SOB) that increases with activity. She also
has epigastric pain with nausea that has been intermittent for 20-30 minutes over
the last three days. She reports that her
epigastric pain has gotten worse and is now radiating into her neck. Her husband
called 9-1-1 and she was transported to
the hospital by emergency medical services (EMS).
Personal/Social History:
JoAnn is a recently retired math teacher who continues to substitute teach part-
time. She is physically active and lives
independently with her spouse in her own home. She has smoked 1 pack per day
the past 40 years. JoAnn appears anxious
and immediately asks repeatedly for her husband upon arrival.
What data from the histories are RELEVANT and have clinical significance to
the nurse?
Patient been having left sided weakness for three days, shortness of breath
increases with activity, denies chest pain, she also has epigastric pain with
nausea that has been intermittent for 2o-30 minutes over the last three days
epigastric pain has gotten worse now radiating into her neck and she also
feels anxious and she smokes one pack per day for the past 40 years
These signs and symptoms are related to a coronary artery disease and
she could be having a heart attack
[Date]
, Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment
(5th VS):
T: 99.2 F/37.3 C (oral) Provoking/Palliative: Nothing/Nothing
P: 128 (regular) Quality: Ache
[Date]
