Question

Clinical Note

Age     58             Sex           M        Date

Chief complaint "Pain on my chest" on and off for the past six months.

History of present illness Mr. Solomon is a 58 year old insurance broker who presents tonight in the office following an episode of "chest pain" that he experienced earlier in the day during a golf game. Although he minimizes the severity of the pain and attributes it to being "out of shape," his wife insisted that he see a physician because he has had similar episodes during the past six months.

Mr. Solomon describes the pain as being more of a discomfort or heaviness. It is localized to "my breast bone" and does not radiate. Today, following a brief rest, the pain subsided and he returned to his golf game. Previous episodes of the heavy feeling tended to occur following large meals and one occasion, while dancing at a wedding. None of the episodes lasted more than "several minutes."

Although Mr. Solomon did not experience nausea or vomiting today, he notes many episodes in the past of feeling a burning sensation in his chest. He describes the sensation as being "like acid behind my breast bone." This feeling occurs most often late at night when he lays down. Usually he has had a large meal or drank alcohol. The sensation does not radiate.

Patient's perspective: When asked about how he feels about these episodes, he admits to being concerned about his health and longevity, considering his father died at age 52 of "heart problems." He says, business is poor, my kid is always in trouble. "Who’s going to take care of things?"

Past Medical history: Not significant

Past Surgical History: None

Family History: Father died of "heart problems" at the age of 52.

Social History: Mr. Solomon smokes � to 1 pack of cigarettes per day. He drinks 2-3 cocktails per nights to "settle my nerves."

Medications: Vitamins

Allergies: None

Review of systems: No significant problems

Physical Examination

Mr. Solomon is a short, moderately obese man who appears somewhat anxious but is in no apparent distress. He is wearing clean casual shirt/pants. Vital sings: BP right arm 162/94; left arm 160/92. Weight 176lbs; Height 5’7". Respiratory rate is 16/minute. Temperature, 98.4� F.

Examination of cardiovascular system reveals a regular, apical heart rate of 86/minute. S1 is heard best at the apex; a loud S2 is heard best in the R2ICS and L parasternal border. A questionable S4 is heard at the apex. There are no murmurs or apical prominence. There is no peripheral edema.

Lungs are clear to percussion and auscultation. An indirect hernia is noted in the right inguinal region. The abdomen is examination is negative for abnormalities.

LABORATORY TESTS:

CBC: WBC = 5,600/mm3, hemoglobin = 15.2g/dL, hematocrit = 45%, platelet count = 320,000/mm3

Chemistries: Glucose 110mg/dL, Blood Urea Nitrogen (BUN) 11mg/dL, Creatinine 0.9mg/dL

Urinalysis: Specific gravity: 1.016; Protein, Glucose, Ketones = negative.

Chest X-ray: normal

QUESTION:

1. Trace the pathophysiology of disease.

2. Make at least 2 nursing care plan based on your assessment that needs to prioritize.

3. What are your discharge plan or recommendation to C.D. using the mnemonic

   METHOD

a.M-Medication

b.E-Environment/Exercise

c.T-Treatment

d.H-Health Teachinge.

O-Observation/Out-patientf.

D-Diet

Answer 1

1. ANGINA PECTORIS - STABLE ANGINA

DEFINITION : Angina is due to poor blood flow through the blood vessels in the heart.

Stable angina is chest pain or discomfort that most often occur with activity or emotional stess

EPIDEMIOLOGY :

Angina pectoris is more often the presenting symptom of coronary artery disease in women than in men, with a female to male ratio of 1.7:1.

It has an estimated prevalence of 4.6 million in women and 3.3 million in men.

CAUSES :

- Atherosclerosis

- Coronary artery spasm

- Anemia

- Aortic stenosis

SIGNS & SYMPTOMS

- Mild to moderate pain

- pain during physical exertion

- Pain is substernal

- Apprehension

- May feel like gas or indigestion

- Usually lasts short time ( less than 5 min )

- Relieved by rest or medicine

DIAGNOSIS

* ECG : ST segment depression

* Cardiac enzymes - may be normal in angina

TREATMENT AND MANAGEMENT

Emergency management:-

- Oxygen

- Nitroglycerin

- Aspirin

* ACE inhibitors

* Beta blockers

* Calcium channel blockers

* Follic acid and Vitamin B12 - to strengthen myocardium

* Homocysteine

* Administer oxygen at 3L /min to receive ischemia.

* Low saturated fat and sodium diet

* Weight control

* Control LDL

* Avoid abuse

There is no significance of laboratory examination performed to the patient

Thankyou