NURS 4080 Unit D Case Study Mr. Adams is a 60 year old who started having chest pain one hour after dinner while he was watching television. He described the pain as a “grabbing pressure” located substernally. He rated his pain a 4 on a scale of 1-10. He stated that the pain radiated down his left arm and through his back. He was transported to the Emergency Department (ED) by ambulance. On admission, Mr. Adams was pale and diaphoretic and complained of shortness of breath. He denied nausea or vomiting. In the ED, unstable angina was diagnosed and tests to rule out myocardial infarction (MI) were initiated. At the time of his arrival in the ED at 8:13 pm he had experienced chest pain for about one hour. The patient reports no previous episodes of chest pain or pressure. He has smoked two packs of cigarettes daily for 25 years. His mother died of Alzheimer’s disease and his father died of cancer. He has no family history of heart disease. On initial examination he had an S3 heart sound, no S4 or murmurs. There were vesicular lung sounds with scattered wheezes, but no crackles were heard. No edema was present, and bowel sounds were normal. Vital signs on admission: BP: 140/90 HR: 92 bpm and regular Respirations: 32 breaths/min. Temperature: 36.9 C SaO2: 95% on 4 l/min nasal cannula Height: 173 cm Weight: 105 kg The 12 lead ECG showed sinus rhythm with frequent premature ventricular contractions (PVCs) and a three to four beat run of ventricular tachycardia (VT). There was a 1-2 mm ST segment elevation in leads I, AVL, and V2-V6. There was also ST segment depression in leads III and AVF. There were Q waves in V2 through V4. The chest x-ray revealed slight cardiomegaly with mild congestive heart failure (CHF). 1 NURS 4080 Unit D Case Study Cardiac enzymes were as follows. CK (U/L) CK-MB (%) Troponin (ng/ml) Admission-8:13 pm 254 10 3.5 12:13 am 7357 >300 >50 04:13 am 5638 >300 >50 In the ED, Mr. Adams’ chest pain was unrelieved after three sublingual nitroglycerin (NTG) tablets. Morphine sulfate 5mg intravenous push (IVP) was administered resulting in some pain relief. The physician diagnosed an extensive anteriolateral MI.

The patient did not have contraindications for thrombolytic therapy and tPA was administered. A NTG drip (50mg in 250 cc D5W) was initiated at 20 mcg/min. A heparin bolus of 8000 units was given and a drip was begun at 10 ml/hr. Metroprolol titrate ( Lopressor®) 5mg IVP was given every 5 minutes X 3 doses. An enteric coated aspirin was administered. The patient was then transferred to the coronary care unit (CCU). On admission to the CCU, Mr. Adams’ chest pain resumed. He rated it a 7/10. His BP was 96/60 mm Hg, and he began having ST segment elevation on the monitor. Three sublingual NTG tablets were given followed by morphine 4 mg IV. The pain did not decrease. The physician was notified and the patient was transferred to the heart catheterization laboratory for angiography and possible angioplasty. The coronary angiogram showed a 90% blockage of the left anterior descending (LAD) artery and the circumflex artery. Despite balloon angioplasty, the left anterior artery continued to re occlude. A stent was placed. Mr. Adams became diaphoretic and his blood pressure dropped to 96/60 and he had several short runs of VT. His oxygen saturation (SaO2) dropped to 86%, so he was placed on a 100% non-rebreather mask and given Amiodarone 150mg IV followed by 360 mg IV over 6 hours and then a drip. Dobutamine was started at 5 mcg/kg/min. *Questions: 1. Describe angina pectoris and discuss the difference between chronic stable angina, unstable angina, and variant angina. 2 NURS 4080 Unit D Case Study 2. Define coronary artery disease (CAD) and discuss the associated risk factors. 3. Describe the pathophysiology behind a MI. What are the effects on the heart and lifestyle? 4. Identify the cardiac enzymes used to help diagnose Mr. Adams MI. Why is it important to test these multiple times? 5. List common symptoms of an acute myocardial infarction (AMI). 6. What is the significance of Mr. Adams’ ST-segment changes? 7. What are the desired pharmacologic effects of NTG? 8. Discuss the pharmacological effects of morphine. 9. Why was Mr. Adams given ASA in the ED? Lopressor? 3 NURS 4080 Unit D Case Study 10. What are the contraindications for tPA? 11. What is a coronary stent? Why was it used on Mr. Adams? 12. What are the therapeutic effects of dobutamine that are important in Mr. Adams’ case? 4 …