Case Presentation

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Case Presentation

on

Coronary Artery Disease, Acute Myocardial Infarction

In Partial Fulfillment of the Course Requirements in

Nursing Care Management

Presented to the Clinical Instructors of

Ateneo de Davao University

Nursing Division

Submitted to:

Anselmo Lafuente, R.N.

Clinical Instructor

Submitted by:

Yap, Novelynne Joy A.

4H

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February 22, 2007

INTRODUCTION

Coronary Artery Disease (CAD) is characterized by the presence of atherosclerosis in the epicardial coronary arteries. Atherosclerotic plaques, the hallmark of atherosclerosis, progressively narrow the coronary artery lumen and impair myocardial blood flow. The reduction in coronary artery flow may be symptomatic or asymptomatic, may occur with exertion or at rest, and may culminate in a myocardial infarction, depending on obstruction severity and the rapidity of development.

The term myocardial infarction is derived from myocardium (the heart muscle) and infarction (tissue death due to oxygen starvation). Myocardial infarction (MI) is the rapid development of myocardial necrosis caused by a critical imbalance between the oxygen supply and demand of the myocardium. This usually results from plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium.

Cardiovascular disease is the leading cause of mortality in the United States among both men and women in every major ethnic group. It accounts for nearly 1 million deaths per year and was responsible for one in five deaths in the United States in 2001. Approximately 6 million men have a history of a myocardial infarction, angina pectoris, or both. Coronary artery disease is the most common form of cardiovascular disease. In 2001, the death rate from coronary artery disease was 228 per 100,000 white men, 262 per 100,000 black men, 137 per 100,000 white women, and 177 per 100,000 black women. The estimated prevalence of coronary artery disease in men is 6.9%; among women the prevalence is 6.0%.

Internationally, diseases of the heart are the leading cause of death, causing a higher mortality than cancer (malignant neoplasms). Some 7,200,000 men and 6,000,000 women are living with some form of coronary heart disease. 1,200,000 people suffer a (new or recurrent) coronary attack every year, and about 40% of them die as a result of the attack. This roughly means that every 65 seconds, an individual dies of a coronary event.

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In the Philippines, 92 percent of Filipinos 20 years and above have at least one of the risk factors that may soon lead to coronary artery disease and cardiovascular disease if not addressed immediately. These risk factors include diabetes, hypercholesterolemia (high cholesterol levels in the bloodstream), obesity, high blood pressure and smoking. In addition the National Nutrition and Health Survey (NNHeS) report also showed that 22 out of 100 Filipino adults are hypertensive (with blood pressure of 140/90 or higher), and 40 percent of those between 20 and 29 already have prehypertensive findings.

During my clinical exposure in the Coronary Care Unit at the Davao Medical Center last November 27-29, 2006, I had a patient with a diagnosis of CAD, AMIK II, (+) LVH, (+) LVD, FC III. This patient is Mr. Perfecto Pandacan Balili, a 60 years old male and will be the focus of my case study.

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OBJECTIVES

General Objective:

Through this paper, I will be able to present details about Coronary Artery Disease, Myocardial Infarction. The proponent gathered data through interviewing the patient and his watchers, making use of the patient’s records from the hospital, and other researches to provide the readers information about the said condition.

This case study would preserve and improve the quality of nursing responsibilities by rendering care, holistically, spiritually, and whole heartedly in a manner that the client, the student nurses and others would benefit.

This case study would be able to:

• COGNITIVE: Discuss in details of the chosen illness for the case study so as to gain insight and knowledge about CAD, AMI

• AFFECTIVE: Have a purposeful interaction with the client’s significant others

• PSYCHOMOTOR: Enhance the ability to identify and apply nursing interventions to provide a better care for the client’s suffering from the mentioned illness.

Specifically, this paper would be able to:

• Present the patient’s personal data with accuracy

• Present the genogram that includes the disease of the family members

• Discuss the health status of the patient that includes the past and present condition

• Present and discuss the complete diagnosis of the patient

• Interpret and discuss the developmental data of the patient

• Obtain the physical assessment of the patient

• Discuss the anatomy and physiology of the affected system

• Trace the pathophysiology of the disease and its underlying causes in relation to the patient’s predisposing and precipitating factors

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• Discuss the different laboratory and diagnostic examinations done top the patient

• Make a drug study on the drugs prescribed to the patient

• Formulate nursing care plans for the patient

• State the prognosis and relate it with the patient’s condition

PATIENT’S DATA

Patient’s Name: Perfecto Pandacan Balili Hospital Number: 919684 Age: 60 years old

Sex: Male

Address: Barangay 76-A, Sabrosa Village, Ecoland, Davao City Civil Status: married

Religion: Roman Catholic Citizenship: Filipino Birthday: July 9, 1946 Birthplace: Tagum City

Name of Spouse: Lydia Balili Age: 57 years old

Name of Father: Julio Balili (Deceased)

Name of Mother: Vicenta Pandacan (Deceased)

Area: Coronary Care Unit Bed: 1

Attending Physician: Dr. Voltaire Egnora

Medical Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killip’s II, Left Ventricular Hypertrophy, Left Ventricular Dilatation, FC III

Chief Complaint: Dyspnea

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LEGEND:

Couple Hypertension Rheumatic Heart Disease

Deceased Heart Problem Renal Failure

Asthma Pulmonary Tuberculosis Arthritis

Cancer CAD, AMI Pneumonia

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HEALTH STATUS

A. Personal Data

Patient’s Name: Perfecto Pandacan Balili Age: 60 years old

Sex: Male

Address: Barangay 76-A, Sabrosa Village, Ecoland, Davao City Chief Complaint: Dyspnea

Medical Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killip’s II, Left Ventricular Hypertrophy, Left Ventricular Dilatation, FC III

B. Family Background

The family has been living in Ecoland ever since Perfecto and Lydia got married, except for some years in between when the family went to Manila but apparently they also came back here in Davao. The couple has eleven children with 6 girls and 5 boys. Aside from that within the 6 girls there is a twin and the same applies with the 5 boys, apparently their third set of twins died due to miscarriage.

Among the eleven children only two of them were able to finish college and the rest were only able to study until their high school years for varied reasons. In addition, currently the couples children are in Manila, one is in Japan and three stayed here in Davao. All of their children are currently married except for the youngest three.

Mr. Perfecto Balili has an educational attainment of until second year high school and his wife Lydia got until second year College with a course of Accountancy. According to Mrs. Balili they got married when she was in third year high school because she already got pregnant with their first child. But even though this is the case she still continued her schooling until second year college with the financial support of her husband. In addition, she got pregnant with only a years difference on all of her children.

Perfecto has always been a taxi driver. He supported his family’s daily needs, educational needs and others with only this kind of job. He worked as a taxi driver both here in Davao and even when they came to Manila he also worked as an FX driver. Back then when their children was young Mr. Perfecto is the only one that works because Lydia is the one that takes care of the children and until today she is still a plain house wife. But when Mr. Balili experienced his first

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heart attack in Manila, he temporarily stopped driving and took a rest. After a few months he then continued his work and did not totally stop driving until after his third attack and so their children are the ones that supported the family. Currently, they get their financial support in their daughter who is in Japan.

Some of his vices include drinking and smoking. He is a hard drinker and started drinking when he was only a teenager. He can consume half a box of cigarette in a day and this started during his twenties. He is also fond of eating meat compared to fish and vegetables.

Furthermore, Perfecto’s father died due to cancer and his mother died due to asthma. Among his siblings, 3 of his siblings had pulmonary tuberculosis namely Emilio, Carlos and Lucia. One of his sisters had a renal failure and hypertension. Other than that they have no trace of any hereditary diseases. Perfecto’s son, Adrian, had PTB and 3 of his children had pneumonia. His daughter, Jackilyn, had Rheumatic Heart Disease and his son, Jeffrey, had asthma.

C. History of Past Illness

Back in 1986, Perfecto was diagnosed of pulmonary tuberculosis and he sought medical help from the Barangay Health Center. He was then given the 6 months treatment for PTB, after the completion of the medication the patient failed to have a follow-up check-up after the treatment.

Perfecto had his first attack 7 years ago; he had his first and second heart attack in Manila. During his first attack he was admitted in Manila Hospital then was transferred to San Juan Hospital for five days and was then brought back to Manila Hospital. His third and fourth heart attack happened in Davao. He was admitted in Med-Main in DMC on his third attack and his fourth attack was in Med CP for he had COPD and was then transferred to CCU for he was diagnosed with Coronary Artery Disease basing on his result of Echocardiogram. His fourth attack happened only last July 2006.

D. History of Present Illness

One month PTA, the patient had his available oxygen via oxygen tank in his house as aid for his breathing, which they bought for P4,500. He also had an air conditioned room at his home just to aid his condition. Two weeks PTA, patient had bipedal edema, loss weight; decrease appetite and experienced paroxysmal nocturnal dyspnea. He had difficulty sleeping during the night. Three days PTA, patient has been having episodes of chest pain at the left anterior chest

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radiating to the arm, lasting for a minute. Five hours PTA, he had recurrence of chest pain of the same character. He then took isosorbide mononitrate SL but without relief. Persistence of symptoms prompted this admission, with a previously diagnosed coronary artery disease by 2D Echo result.

E. Effects and Expectation of Illness to Family

Mr. Perfecto already had five heart attacks and his condition got worse every time this happens. Although the family is very well aware of his degenerating condition they are still hoping that he will get better and that will live much longer. As observed the family is not really affluent and that they are having financial problems due to the recurrent attacks of the patient. Luckily, they are being assisted by his daughter, Jackilyn, who had a Japanese husband and currently resides in Japan. In addition, he also had a senior citizen’s identification card that becomes a big aid in their financial needs. Aside from the financial help the family is greatly affected by the patient’s condition and thus still tries their best to live a normal life.

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COMPLETE DIAGNOSIS

Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killip’s II, Left Ventricular Hypertrophy, Left Ventricular Dilatation, FC III

Coronary

• Term applied to vessels

(Stedman’s Medical Dictionary, 25th_Edition)

• Used to describe the arteries that supply blood to the muscle tissue of the heart, or the veins that take blood away from it

(Microsoft® Encarta® Premium Suite 2005)

• Relating to or being the coronary arteries or coronary veins, or relating to the heart (http://education.yahoo.com/reference/dictionary/entry/coronary)

Artery

• A vessel through which the blood passes away from the heart to the various parts of the body

• Blood vessel that carries blood away from the heart

(Medical Dictionary by Gupta and Gupta)

• Are muscular blood vessels that carry away blood from the heart

(http://en.wikipedia.org/wiki/Artery)

Disease

• A definite morbid process having a characteristic train of symptoms

• Any departure from health of a structure, organ, or system

• Disorder with a specific cause and recognizable signs and symptoms, any bodily abnormality or failure to function properly

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Coronary Artery Disease

• A disease in which there is a narrowing or blockage of the coronary arteries (blood vessels that carry blood and oxygen to the heart

(Medical-Surgical Nursing, 9th_Edition)

• Characterized by the presence of atherosclerosis in the epicardial coronary arteries. (The Bantam Medical Dictionary)

• Occurs when the arteries that supply blood to the heart muscle (the coronary arteries) become hardened and narrowed

(http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html)

Acute

• Having rapid onset, short or relatively severe course

Myocardial

• Pertaining to the muscular tissue of the heart

• Relating to or affecting the thick muscular wall of the heart.

• The middle of 3 layers forming the wall of the heart. It is composed of cardiac muscles and forms the greater part of the heart wall, being thicker in the ventricles than in atria.

(http://education.yahoo.com/reference/dictionary/entry/myocardial)

Infarction

• Formation of an infarct (coronary thrombosis)

• Cessation of blood flow by thrombus formation and causing issue death

• The death of part of the whole of an organ that occurs when the artery carrying its blood supply is obstructed by a blood clot

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Killip’s II

• A classification of Acute Myocardial Infarction that is defined as having moderate heart failure with basiliar rales -50% of lung field or S3 gallops, tachycardia or signs and symptoms or right heart failure like venous or hepatic congestion

(Harrison’s Internal Medicine)

Myocardial Infarction

• A disease that occurs when the blood supply to a part of the heart is interrupted. The resulting oxygen shortage causes damage and potential death of heart tissue

(http://en.wikipedia.org/wiki/Myocardial_infarction)

• Is the rapid development of myocardial necrosis caused by a critical imbalance between the oxygen supply and demand of the myocardium

(http://www.clevelandclinicmeded.com/diseasemanagement/cardiology/complications/compl ications.htm)

• It is a disease that occurs when the blood supply to a part of the heart is interrupted

(http://www.yahoo.com/reference/dictionary/acutemyocardial infarction)

Ventricular

• Pertaining to ventricles

• Involving, affecting or relating to a ventricle

• One of the chambers of the heart, the largest and the most important chamber

(www.ask.com/dictionary/left ventricle)

Hypertrophy

• Morbid enlargement or overgrowth of an organ or part due to an increase in size of its constituent cells

• An increase in cell size

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• Increase the size of a tissue or organ brought about by the enlargement of its cells rather than by cell multiplication, muscles undergo these changes in response to increased work

(http://education.yahoo.com/reference/dictionary/hypertrophy)

Dilatation

• The act or process of widening or being widened, stretching or being stretched, or enlarging or being enlarged

• something, especially a part of something else, that has become enlarged, expanded, or stretched

• The enlargement or expansion of a hollow organ or cavity

(The Bantam Medical Dictionary)

Left Ventricle Hypertrophy & Dilatation

• There were increase in the size of the left ventricle or enlargement of the left ventricle due to increase blood volume and pressure

(http://education.yahoo.com/reference/dictionary/hypertrophy/dilatation)

FC III

• A classification of chronic heart failure that is defined as having dyspnea that occurs with less than ordinary physical activity, can climb one or less than one flight of stairs

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DEVELOPMENTAL DATA

The middle years from 40-65, have been called the years of stability and consolidation. For most people it is the time when children have grown and moved away or are moving away from home. Thus, partners generally have more time for and with each other and time to pursue interests they may have deferred for years.

Physical Development

A number of changes take place during the middle years. Both men and women experience decreasing hormonal production during the years. The climacteric (andropause) refers to the changes of life in men, when sexual activity decreases. In men, there is no change comparable to menopause in women. Androgen levels decreases very slowly; however men can still have children even in late life. The psychological problems that men experience is generally relate to fear of getting old and to retirement, boredom and finances.

Physical changes that occurred to Perfecto were his decreasing ability to perform activities. He easily gets tired and constantly needs assistance upon doing things or moving about. Due to his condition he only has limited capabilities and can no longer do what he usually does unlike the previous years before his first attack occurred.

Robert Havighurst’s Developmental task theory

Since Perfecto belonged to the middle-aged group, he had seven tasks to accomplish according to Havighurst’s theory. These tasks are:

1. Achieving adult, civic and social responsibility. The family agreed that Perfecto has achieved this because he was able to perform his role well. He is able to support his eleven children and send them to school although unfortunate personal circumstances hindered eight of them from finishing school. Although this is the case Perfecto is a responsible citizen and is concerned for the betterment of his family and community. 2. Establishing and maintaining an economic standard of living. Perfecto works really hard for his family. Ever since he got married he did his best to support his family. He did a very good job since he was also able to support the schooling of his wife. He worked as a taxi driver both here in Manila and Davao.

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3. Assisting teenage children to become responsible and happy adults. He is the authority of the house and he makes sure that he is able to guide his children to the right path. Many of his children did not finish their schooling because many are just not interested to do so and there may be lack of guidance since they were a big family and their behavior was affected by the changing environment. Although this is the case his children as adults are responsible enough to work hard to support each other and help the family especially when the family is on financial crisis.

4. Developing adult leisure time activities. They spend they leisure time talking at each other, watching television or talking to neighbors and establish good relationships. Back then he would smoke and drink with his male friends but ever since he ha his first attack he stopped his vices.

5. Relating oneself to one’s spouse as a person. Usual petty fights happen between the couple but they are able to patch things up and still work as a couple. They value each others opinion and respect each others decisions.

6. Accepting and adjusting to the physiologic changes of middle age. Perfecto had accepted the fact that he is not getting any younger anymore and it is evident on his condition. That is why he already anticipated any changes that would happen to him especially with his current illness. He is very well aware that his body is no longer like before and that each attacks that occurs is worse than the previous.

7. Adjusting to aging parents. Perfecto’s parents died many years ago and so he is very well adjusted now and accepted the fact that everyone dies eventually.

Psychosocial Development

According to Erik Erikson, a person develops throughout his lifetime. He noted that there are levels of achievement that a person must achieve or experience. These can be achieved and be ranked as partial, complete or unsuccessful. The greater the achievement of a person, the more he is better and healthier in development of hid personality. Failure to achieve the task may affect the person’s ability to achieve the next task.

According to Erik Erikson the middle adulthood belongs to the generativity versus stagnation. In this stage work is most crucial. He observed that middle age is when they tend to be occupied with creative and memorable work and with issues surrounding their family. It is when they expect to “be in charge”, and the significant task is to perpetuate culture and transmit

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values of the cultures through the family and working to establish a stable environment. Strength comes through the care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, and when they are in this stage they often fear inactivity and meaninglessness.

As their children leave home, their goals change and they may be faced with major life changes-midlife crisis- and the struggle with finding new meanings and purposes. If they do not get through this stage successfully, they can become self-absorbed and stagnate.

In the case of my patient, he is on the middle adulthood stage. As of now, he has on the stage wherein he is still guiding some of his children. He is now concerned more on his children’s future. He is aware of social responsibility and develops leisure activities and hobbies appropriate for his age. He previously does his best to become productive and contribute to the society but due to his current condition he is no longer able to do that. But being the head of the family continues to be his role only with restrictions on some actions.

Cognitive Development

Cognitive and intellectual abilities of the middle adult change very little from the young adults. There is motivation to learn, especially if the knowledge gained can be immediately applied and had personal relevance. Problem solving abilities remain throughout adulthood, although the time response may be slightly longer. This is not due to a decrease in ability, but rather due to longer memory research of increased amounts of material.

According to my patient, every problem has a solution. This shows that he is very positive when it comes to problem solving. My patient is able to find solutions to his problems and he does not lose hope that he could not overcome any problem he is experiencing. One example was his admission due to his debilitating illness. He was able to surpass this problem because of his positive attitude towards problem solving. He had undergone 4 attacks before and he was still very positive & opens to any modification regarding his health just to live longer.

Moral Development

The middle adulthood remain at the conventional level or may move to post conventional level, especially if the person had sustained responsibility for the welfare of others and has consistently applied ethical principles developed in adolescence. At this level, the adult believes that the rights of others take precedence and takes steps to support those rights.

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My patient belongs to post conventional level or self accepted moral principles. He is able to distinguish right from wrong. He respected and takes priority the rights of others and also maintains self respect. He believes that relationships are based on mutual trust. He has his personal values as to the standards of our society. He views each of then as right and proper because that is what the society wants. But the decision is still coming from him. He decides on his own if he should follow the things that the society dictates him or simply follow what is right for him.

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PHYSICAL ASSESSMENT

I. General appearance & mental status

Mr. Perfecto Balili, a 60 year old male client, was admitted on November 12, 2006 in Davao Medical Center. Upon assessment the patient was lying on bed in moderate high back rest and is awake, conscious, coherent & responsive. He has an IVF of D5W 500cc @ 300cc level running at KVO infusing well @ right cephalic vein, with O2 inhalation @ 5Liters per minute via nasal cannula, is wearing a hospital gown and has diaper.

The client has a generalize weakness and needs assistance upon moving or position changes. He has difficulty of breathing and is constantly expectorating whitish phlegm into his bedside receptacle. He is 5’6” in height and weighs 59 kg.

II. Vital Signs: BP- 110/80mmHg

CR- 43 bpm; irregular rate and rhythm RR- 25 cpm; regular rhythm

Temp- 36.5’ C

III. Skin

The color of the skin is brown with rough and dry texture. The patient has poor skin turgor and clammy to touch. Scars in lower extremities are observed; no wounds or lesions are noted.

IV. Head

He has a normocephalic configuration with head circumference of 22 cm. His facial movements are symmetric and he has a thin, evenly distributed, white in color hair. Scalp is dry but there is no presence of dandruff or lice upon inspection

V. Eyes

Eyes have symmetrical lids and normal periorbital area. Conjunctiva is pale and sclera is observed to be anicteric. Both left and right pupils are black in color with pupillary size of 3mm,

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briskly reactive to light. He has a slightly sunken periorbital region, eye bugs present with eyebrows and eyelashes evenly distributed. Client wears eyeglasses only upon reading.

VI. Ears

Client’s ears are symmetrical and are in line with the outer canthus of the eyes. His pinnae are normal, normoset and symmetric. No tenderness and lesions noted. Absence of discharges on the external canal is noted. No hearing problem noted.

VII. Nose

The client’s nasolabial fold is normal, septum is medially located and no discharges are noted. There are no deformities or inflammation on the nose noted. No nasal flaring is noted and both nostrils are patent. He has an O2 inhalation via nasal cannula.

VIII. Mouth

The mucosa and gums of the client are pinkish and lips are dry. His tongue is medially located. Teeth were yellowish in color with loose teeth, he do not use dentures. He has no difficulty of swallowing and no halitosis and bleeding noted upon observation.

IX. Neck

There are no signs of abnormal growth or enlargement of the nodes of the neck of the client. There are no lesions noted.

X. Chest and Lungs

The client has rapid, regular breathing at the rate of 25 cpm. Wheezing is noted upon auscultation with symmetrical chest expansion. He has productive cough with whitish phlegm..

XI. Heart and Breast

The client has symmetrical, rounded shape breast with smooth surface. The areolas are bilaterally the same and are dark brown in color. There are no masses, lesions or tenderness noted on these areas. He has a capillary refill time of 4 seconds. His pericardial area is flat and heart sound is weak and irregular in rate and rhythm with a rate of 43 bpm. He is hooked to a

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cardiac monitor with Atrial Fibrillation in slow to moderate response with ST elevation pattern. An IVF of D5W 500cc @ KVO rate infusing well @ right cephalic vein @ 300cc level

XII. Abdomen

The skin in this area has uniform color and no lesions; with flat abdominal contour thus there is no evidence of an enlarged spleen or lived noted. He has normal bowel sound of one every 15 seconds.

XIII. Genito-Urinary

The client wears diaper but voids freely. There are no lesions or discharges noted. He can defecate without difficulty at least once a day.

XIV. Back and Extremities

Client needs assistance upon moving around and in doing activities of daily living. He can extend and flex both his upper and lower extremities with (-) bipedal edema or anasarca. Weakness upon movement is noted. He has dirty and untrimmed nails on all extremities.

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ANATOMY and PHYSIOLOGY

The cardiovascular system is sometimes called the blood-vascular or simply the circulatory system. It consists of the heart, which is a muscular pumping device, and a closed system of vessels called arteries, veins, and capillaries. As the name implies, blood contained in the circulatory system is pumped by the heart around a closed circle or circuit of vessels as it passes again and again through the various "circulations" of the body. It transports food, hormones, metabolic wastes, and gases (oxygen, carbon dioxide) to and from cells. Components of the circulatory system include:

• blood: consisting of liquid plasma and cells

• Blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which carry blood to/from all tissues. (Arteries carry blood away from the heart. Veins return blood to the heart. Capillaries are thin-walled blood vessels in which gas/ nutrient/ waste exchange occurs.)

• heart: a muscular pump to move the blood

The Cardiovascular System

In order to pump blood through the body, the heart is connected to the vascular system of the body. This cardiovascular system is designed to transport oxygen and nutrients to the cells of the body and remove carbon dioxide and metabolic waste products from the body. The cardiovascular system is actually made up of two major circulatory systems, acting together. The right side of the heart pumps blood to the lungs through the pulmonary artery (PA), pulmonary capillaries, and then returns blood to the left atrium through the pulmonary veins (PV). The left side of the heart pumps blood to the rest of the body through the aorta, arteries, arterioles, systemic capillaries, and then returns blood to the right atrium through the venules and great veins.

There are two circulatory "circuits": Pulmonary circulation, involving the "right heart," delivers blood to and from the lungs. The pulmonary artery carries oxygen-poor blood from the

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"right heart" to the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary veins carry oxygen-rich blood from the lungs back to the "left heart." Systemic circulation, driven by the "left heart," carries blood to the rest of the body. Food products enter the system from the digestive organs into the portal vein. Waste products are removed by the liver and kidneys. All systems ultimately return to the "right heart" via the inferior and superior vena cava.

A specialized component of the circulatory system is the lymphatic system, consisting of a moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, and organs (bone marrow, liver, spleen, thymus). Through the flow of blood in and out of arteries, and into the veins, and through the lymph nodes and into the lymph, the body is able to eliminate the products of cellular breakdown and bacterial invasion.

Blood Components

• Forty-five percent (45%) consists of cells - platelets, red blood cells, and white blood cells (neutrophils, basophils, eosinophils, lymphocytes, monocytes). Of the white blood cells, neutrophils and lymphocytes are the most important.

• Fifty-five percent (55%) consists of plasma, the liquid component of blood. Major Blood Components

Component Type Source Function

Platelets, cell fragments Bone marrow life-span: 10 days

Blood clotting

Lymphocytes (leukocytes) Bone marrow,

spleen, lymph nodes

Immunity

T-cells attack cells containing viruses. B-cells produce

antibodies. Red blood cells (erythrocytes), Filled with

hemoglobin, a compound of iron and protein

Bone marrow Oxygen transport Neutrophil (leukocyte) Bone marrow Phagocytosis

Plasma, consisting of 90% water and 10% dissolved materials -- nutrients (proteins, salts, glucose), wastes (urea, creatinine), hormones, enzymes 1. Maintenance of pH level near 7.4 2. Transport of large molecules (e.g. cholesterol) 3. Immunity (globulin) 4. Blood clotting

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(fibrinogen) Vascular System - the Blood Vessels

Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run parallel throughout the body with a web-like network of capillaries connecting them. Arteries use vessel size, controlled by the sympathetic nervous system, to move blood by pressure; veins use one-way valves controlled by muscle contractions.

Arteries

Arteries are strong, elastic vessels adapted for carrying blood away from the heart at relatively high pumping pressure. Arteries divide into progressively thinner tubes and eventually become fine branches called arterioles. Blood in arteries is oxygen-rich, with the exception of the

pulmonary artery, which carries blood to the lungs to be oxygenated.

The aorta is the largest artery in the body, the main artery for systemic circulation. The major branches of the aorta (aortic arch, ascending aorta, descending aorta) supply blood to the head, abdomen, and extremities. Of special importance are the right and left coronary arteries

that supply blood to the heart itself.

Capillaries

The arterioles branch into the microscopic capillaries, or capillary beds, which lie bathed in interstitial fluid, or lymph, produced by the lymphatic system. Capillaries are the points of exchange between the blood and surrounding tissues. Materials cross in and out of the capillaries by passing through or between the cells that line the capillary. The extensive network of capillaries is estimated at between 50,000 and 60,000 miles long.

Veins

Blood leaving the capillary beds flows into a series of progressively larger vessels, called

venules, which in turn unite to form veins. Veins are responsible for returning blood to the heart after the blood and the body cells exchange gases, nutrients, and wastes. Pressure in veins is low, so veins depend on nearby muscular contractions to move blood along. Veins have valves that prevent back-flow of blood.

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Blood in veins is oxygen-poor, with the exception of the pulmonary veins, which carry oxygenated blood from the lungs back to the heart. The major veins, like their companion arteries, often take the name of the organ served. The exceptions are the superior vena cava and the inferior vena cava, which collect body from all parts of the body (except from the lungs) and channel it back to the heart.

Artery/Vein Tissues

Arteries and veins have the same three tissue layers, but the proportions of these layers differ. The innermost is the intima; next comes the media; and the outermost is the adventitia. Arteries have thick media to absorb the pressure waves created by the heart's pumping. The

smooth-muscle media walls expand when pressure surges, then snap back to push the blood forward when the heart rests. Valves in the arteries prevent back-flow. As blood enters the capillaries, the pressure falls off. By the time blood reaches the veins, there is little pressure. Thus, a thick media is no longer needed. Surrounding muscles act to squeeze the blood along veins. As with arteries, valves are again used to ensure flow in the right direction.

Anatomy of the Heart

The heart is about the size of a man's fist. Located between the lungs, two-thirds of it lies left of the chest midline. The heart, along with the pulmonary (to and from the lungs) and systemic (to and from the body) circuits, completely separates oxygenated from deoxygenated blood.

Internally, the

heart is designed as a pump with

four chambers - right atrium

(RA), right ventricle (RV),

left atrium (LA), and left ventricle

(LV). The two atria are the

smaller, upper chambers of the

heart and the two ventricles

are the larger, lower chambers

of the heart. The heart is oriented

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degrees to the left lateral side such the right ventricle is the most anterior structure of the heart. The left ventricle is generally about twice as thick as the right ventricle because it needs to generate enough force to push blood through the entire body while the right ventricle only needs to generate enough force to push blood through the lungs. Ventricular contraction forces blood into the arteries.

The heart also has four valves. The tricuspid valve is between the right atrium and right ventricles. The pulmonary valve is between the right ventricle and the pulmonary artery. The mitral valve is between the left atrium and the left ventricle and the aortic valve is between the left ventricle and the aorta. The valves, under normal conditions, insure that blood only flows in one direction in the heart.

Cardiac Muscle

Cardiac muscle is a type of involuntary mononucleated, or uninucleated, striated muscle found exclusively within the heart. Its function is to "pump" blood through the circulatory

system by contracting.

Inside each cardiomyocyte are hundreds of myofibrils which are thin, elongated structures. Each myofibril, in turn, consists of thin filaments and thick filaments. Each of the thin filaments is composed of a protein called actin. Each of the thick filaments is composed of a protein called myosin. Each myosin filament is composed of about 200 myosin molecules. Each myosin molecule contains what is called a myosin head. Inside each cardiomyocyte there are compartments filled with calcium. The action potential causes these compartments to release the calcium into the cell. This calcium allows myosin heads to bind to actin filaments and pull them by a process called a power stroke. That is how action potential causes the individual muscle cells to contract.

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Basic Cardiac Physiology

A basic understanding of cardiac physiology is also essential to interpreting the physical finding during a cardiac exam. Each pump or beat of the heart consists of two parts or phases - diastole and systole. During diastole the ventricles are filling and the atria contract. Then during systole, the ventricles contract while the atria are relaxed and filling.

For the purposes for this discussion of cardiac physiology, we will focus on the physiology associated with the heart sounds S1, S2, S3, and S4. S1 occurs near the beginning of (ventricular) systole with the closing of the tricuspid and mitral valves. The closing of these two valves with increasing pressure in the ventricles as they begin to contract should be simultaneous. Any splitting in which the closing of the two valves are heard separately should be considered pathological. S2 occurs near the end of (ventricular) systole with the closing of the pulmonary and aortic valves. The closing of these two valves occurs with beginning of backward flow in the pulmonary artery and aorta respectively as the ventricles relax. The two valves can occur simultaneously or with slight gap between them under normal physiologic circumstances. S3 occurs at the end of the rapid filling period of the ventricle during the beginning of (ventricular) diastole. An S3, if heard should occur 120-170 msec after S2. S4 occurs, if heard coincides with atrial contraction at the end of (ventricular) diastole.

The Circulation

Poorly oxygenated blood collects in two major veins: the superior vena cava and the inferior vena cava. The superior and inferior vena cava empty into the right atrium. The coronary sinus which brings blood back from the heart itself also empties into the right atrium. The right atrium is the larger of the two atria although it receives the same amount of blood. The blood is then pumped through the tricuspid valve, or right atrioventricular valve, into the right ventricle. From the right ventricle, blood is pumped through the pulmonary semi-lunar valve into the pulmonary artery. This blood leaves the heart by the pulmonary arteries and travels through the lungs (where it is oxygenated) and into the pulmonary veins. The oxygenated blood then enters the left

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atrium. From the left atrium, the blood then travels through the bicuspid valve, also called mitral or left atrioventricular valve, into the left ventricle. The left ventricle is thicker and more muscular than the right ventricle because it pumps blood at a higher pressure. Also, the right ventricle cannot be too powerful or it would cause pulmonary hypertension in the lungs. From the left ventricle, blood is pumped through the aortic semi-lunar valve into the aorta. Once the blood goes through systemic circulation, peripheral tissues will extract oxygen from the blood, which will again be collected inside the vena cava and the process will continue. Peripheral tissues do not fully deoxygenate the blood, thus venous blood does have oxygen, only in a lower concentration in comparison to arterial blood.

The Heart's Conduction System

There are four basic components to the heart's conduction system 1. sinoatrial node (SA node)

2. inter-nodal fibre bundles

3. atrioventricular node (AV node) 4. atrioventricular bundle

The sinoatrial (SA) node is a small mass of specialised cardiac muscle situated in the superior aspect of the right atrium. It lies along the anterolateral margin of this chamber between the orifice of the superior vena cava and the auricle. The specialized cardiac muscle of the SA node is characterized by the property of automatic self-excitation and it initiates each beat of the heart. Therefore, the SA node is often referred to as the pacemaker of the heart.

Since the fibers of the SA node fuse with the surrounding atrial muscle fibers, the action potential generated in the nodal tissue spreads throughout both atria at a rate of approximately 0.3 meter per second and produces atrial contraction. Interspersed among the atrial muscle fibers

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are several inter nodal fiber bundles which conduct the action potential to the atrioventricular (AV) node with a greater velocity (approximately 1.0 meter per second) than ordinary atrial muscle. The AV node is located in the right atrium near the lower part of the interatrial septurn. Here there is a short delay (approximately 0.1 second) in transmission of the impulse to the ventricles.

This is important because it permits the atria to complete their contraction and empty their blood into the ventricles before the ventricles contract. The delay occurs within the fibers of the AV node itself as well as in special junctional fibers that connect the node with ordinary atrial fibers.

Once the action potential leaves the AV node, it enters specialized muscle fibers called Purkinje fibers. These are grouped into a mass termed the atrioventricular (AV) bundle, or the bundle of His. The Purkinje fibers are very large and conduct the action potential at about six times the velocity of ordinary cardiac muscle (i.e., 1.5 to 4.0 meters per second). Thus the Purkinje fibers permit a very rapid and simultaneous distribution of the impulse throughout the muscular walls of both ventricles.

As the AV bundle leaves the AV node, it descends in the interventricular septurn for a short distance and then divides into two large branches, the right and left bundle branches. Each of these descends along its respective side of the interventricular septum immediately beneath the endocardium and divides into smaller and smaller branches. Terminal Purkinje fibers extend beneath the endocardium and penetrate approximately one-third of the distance into the myocardium. Their endings terminate upon ordinary cardiac muscle within the ventricles, and the impulse proceeds through the ventricular muscle at about 0.3 to 0.5 meters per second. This results in a contraction of the ventricles that proceeds upward from the apex of the heart toward its base.

The spontaneous generation of an action potential within the SA node initiates a sequence of events known as the cardiac cycle. Each cardiac cycle lasts approximately 0.8 second and spans the interval from the end of one heart contraction to the end of the subsequent heart contraction. Ordinarily this occurs about 72 times each minute.

Blood Pressure and Heart Rate

The heart beats or contracts around 72 times per minute. The human heart will undergo over 3 billion contraction/cardiac cycles during a normal lifetime.

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One heartbeat, or cardiac cycle, includes atrial contraction and relaxation, ventricular contraction and relaxation, and a short pause. Atria contract while ventricles relax, and vice versa. Heart valves open and close to limit flow to a single direction. The sound of the heart contracting and the valves opening and closing produces a characteristic "lub-dub" sound.

The cardiac cycle has two basic components:

(1) contraction phase (systole) during which blood is ejected from the heart

(2) relaxation phase (diastole) during which the chambers of the heart are filled with blood.

The spontaneous generation of an action potential within the SA nodal tissue represents the start of the cardiac cycle. This electrical impulse spreads throughout the atrial muscle and leads to contraction of the two atria.

As the atria contract, the AV valves remain open and additional blood is forced into the ventricles from the veins. A large amount of blood has already passed from the atria to the ventricles prior to atrial contraction.

The aortic and pulmonary (pulmonic) semilunar valves remain closed.

After the ventricles have filled (mostly by blood returning from the large veins) and the atria have contracted, the AV valves close as the ventricles begin their contraction.

Ventricular contraction forces blood through the semilunar valves into the aorta and pulmonary trunk.

Next, as the ventricles begin to relax, the aortic and pulmonic semilunar valves close, the AV valves open, and blood flows into the ventricles to begin another cycle.

While the atria are in systole, the ventricles are relaxed (in diastole). The atria relax during ventricular systole and remain in this phase even during a portion of ventricular diastole.

Blood (like any other fluid) tends to flow from a region of high pressure to one of lower pressure.

As each chamber of the heart fills with blood, the pressure increases within it. The blood moves out of the chamber, when the various one-way valves guarding those chambers permit it to do so.

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As the ventricles contract, the blood is forced in a retrograde fashion against the AV valves, which causes them to bulge inward slightly toward the atria and which also elevates atrial pressure.

In doing so, the AV valves are effectively closed and blood is prevented from regurgitating back into the atria. Near the end of ventricular systole the AV valves are still closed and since the atria are in the process of filling, this too contributes to a rise in intra-atrial pressure.

Even before the atria enter systole, the ventricles are filled with blood to approximately 70% of their capacity. When the atria do finally contract, additional blood enters the ventricles and elevates the intraventricular pressure. As the ventricles contract, blood is forced backward, closing the AV valves, and a sharp rise in ventricular pressure occurs.

Although the ventricles exist as closed chambers for a brief moment, the pressure within them soon exceeds that in the aorta and pulmonary trunk. When this happens the aortic and pulmonic semilunar valves are forced open under pressure and blood rushes out of the ventricles and is driven into these large vessels. Accompanying the opening of the semilunar valves is a rapid decline in intraventricular pressure that continues until the pressure within the ventricles becomes less than that of the atria. When this pressure differential is reached, blood within the atria pushes the AV valves open and begins to fill the ventricles once again.

Receptors in the arteries and atria sense systemic pressure. Nerve messages from these sensors communicate conditions to the medulla in the brain. Signals from the medulla regulate blood pressure.

Electrocardiography (ECG, EKG)

An electrocardiogram measures changes in electrical potential across the heart and detects contraction pulses that pass over the surface of the heart. There are three slow, negative changes, known as P, R, and T. Positive deflections are the Q and S waves. The P wave represents atrial contraction ("the lub"), the T wave the ventricular contraction ("the dub").

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The Lymphatic System

The lymphatic system functions 1) to absorb excess fluid, thus preventing tissues from swelling; 2) to defend the body against microorganisms and harmful foreign particles; and 3) to facilitate the absorption of fat (in the villi of the small intestine).

Capillaries release excess water and plasma into intracellular spaces, where they mix with lymph, or interstitial fluid. "Lymph" is a milky body fluid that also contains proteins, fats, and a type of white blood cells, called "lymphocytes," which are the body's first-line defense in the immune system.

Lymph flows from small lymph capillaries into lymph vessels that are similar to veins in having valves that prevent backflow. Contraction of skeletal muscle causes movement of the lymph fluid through valves. Lymph vessels connect to lymph nodes, lymph organs (bone marrow, liver, spleen, thymus), or to the cardiovascular system.

• Lymph nodes are small irregularly shaped masses through which lymph vessels flow. Clusters of nodes occur in the armpits, groin, and neck. All lymph nodes have the primary function (along with bone marrow) of producing lymphocytes.

• The spleen filters, or purifies, the blood and lymph flowing through it.

• The thymus secretes a hormone, thymosin, which produces T-cells, a form of lymphocyte.

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PATHOPHYSIOLOGY

Predisposing Factors Present (√) / Absent (x) Rationale

Family History X

Individuals with history of heart diseases within their family or first degree relatives are more prone in developing one himself. The presence of coronary atherosclerosis in a parent or sibling under 50 years old is associated with the same finding in another family member.

Age √ More common in male aged (45 -70 y.o.)

Gender √

Men are at a greater risk for the development of CAD. Women are usually not affected by this disease until after menopause. Postmenopausal increase has been attributed to decrease levels of estrogens and rising blood lipids.

Race X Black Americans have a higher risk than whites. This is because they have increased incidence of hypertension (33%)

Precipitating Factors Present (√) / Absent (x) Rationale Past Present

Cigarette smoking √ X

Inhalation of smoke increases the blood carbon monoxide level causing hemoglobin, the oxygen carrying component of blood to combine more readily with carbon monoxide than with oxygen resulting to decrease amount of available oxygen which may decrease the heart’s ability to pump.

Nicotinic acid in tobacco triggers the release of catecholamines which raises both heart rate and blood pressure. It can also cause the coronary arteries to constrict and increase catecholamines may be a factor in the increased incidence of sudden heart death. It could also cause detrimental vascular response and increase platelet adhesion leading to high probability of thrombus formation.

Hyperlipidemia X X

This refers to the elevation of cholesterol and triglyceride levels within the blood. Cholesterol can be obtained directly from animal dietary source or manufactured by the liver and intestine. Triglycerides are derived from fatty acids found in adipose tissue or the diet. Cholesterol and triglycerides are involved

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in the transportation, digestion and absorption of fats.

High levels of low-density lipoproteins are attributed to the development atherosclerosis that would latter on cause obstruction in the artery. LDL unlike HDL could not be metabolized by the body. The HDL cannot carry the bad cholesterol to the liver for metabolism. The macrophages will then need to modify it before HDL could interact with it. During modification the macrophages cause injury to the endothelial wall resulting to fibrous formation and later on to formation of emboli that would lead to obstruction of blood flow to the myocardial artery.

Hypertension √ X

Increase stiffness of the vessel walls leading to vessel injury and a resulting inflammatory response within the intima. It can also increase the work of the left ventricle which must pump harder to eject blood into the arteries. Increase workload causes the heart to enlarge and thicken (hypertrophy) a condition that may eventually lead to cardiac failure.

In addition, increased peripheral vascular resistance associated with hypertension increases afterload and the demand on the left ventricle. The result is an increased demand for myocardial oxygen in the face of a diminished supply.

Sedentary lifestyle X √

It is noted that increase in activity can improve the efficacy of the heart by the reduction of heart rate and blood pressure. It also decreases the level of low-density lipoproteins, lowered blood glucose levels, and improved cardiac output has been associated with lesser chance of CAD.

Diabetes Mellitus X X

Hyperglycemia fosters increase platelet aggregation and altered RBC function, which can lead to thrombus formation. Also, insulin injures the vessel wall leading to inflammatory response.

Obesity X X

Obesity or excess body weight in relation to height increases the workload and hence the oxygen demands of the heart. Obesity highly correlates with hypertension, hyperlipidemia, and diabetes. It is also associated with increased caloric intake and elevated levels of

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low-density lipoproteins.

Stress √ X

Stress stimulates the cardiovascular system by the release of cathecolamines, which in turn increase the heart rate and produce vasoconstriction.

History of CAD √ √

Individuals with history of CAD are more predisposed to reoccurrence or development of heart diseases. Since there is already previous formation of atherosclerosis and obstruction within the myocardial artery the person may then easily develop the same problem. It is also noted that these individuals may have had a portion of their heart than no longer functions properly due to ischemia or necrosis.

Symptomatology Present (√) / Absent (x) Rationale

Dyspnea √

Collection of fats, cells and debris result to development of fatty streaks. Narrowing of epicardial blood vessel due to atheromatous plaque would then result to coronary artery disease. Progressive narrowing of the arterial lumen, body will compensate through vasodialation. But increase in occlusion will result to gradual weakening of the myocardium. Damage to the heart limits the output of the left ventricle. Poor ventricular compliance would result to dyspnea.

Bradycardia √

Development of fatty streaks between the endothelium and internal elastic lamina. Narrowing of epicardial blood vessel due to atheromatous plaque would then result to coronary artery disease. Progressive narrowing of the arterial lumen would result to gradual weakening of the myocardium. This would then result to decrease in the cardiac output.

Pulmonary Edema X

Formation of fatty streaks within the endothelium and lamina. Narrowing of epicardial blood vessel due to atheromatous plaque would then result to coronary artery disease. Progressive narrowing of the arterial lumen, body will compensate through vasodialation. But increase in occlusion will result to gradual weakening of the myocardium. Damage to the heart limits the

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output of the left ventricle. Poor ventricular compliance would result to Pulmonary edema.

Chest pain √

When mural thrombus forms at site of rupture, initial platelet monolayer forms at the site. Various agonists (collagen, ADP, epinephrine, serotonin) promote platelet activation. Production and release of thromboxane A2 result to further platelet activation, and potential resistance to thrombolysis. Von Willebrand factor (vWF) and fibrinogen are multivalent molecules which bind to two different platelets simultaneously, resulting in platelet cross-linking and aggregation. Coagulation cascade is activated on exposure of tissue factor in damaged endothelial cells at the site of the ruptured plaque.

Conversion of prothrombin to thrombin, which then converts fibrinogen to fibrin would result to fluid-phase and clot-bound thrombin participate in an autoamplification reaction that leads to further activation of the coagulation cascade. Coronary artery eventually becomes occluded by a thrombus containing platelet aggregates and fibrin strands. Imbalance between oxygen supply and demand of the myocardium would then lead to compromised myocardial blood flow which does not meet the metabolic demands of myocardial tissue.

S3 heart sound X

Disruption of mid-sized atheromatous plaque due to injury or rupture would result to an injured but still living heart muscle which could still conduct electrical impulses slowly. Speed can become so slow that the spreading impulse is preserved long enough for the uninjured muscle to complete its contraction. Slowed electrical signal still traveling within the injured area can re-enter and trigger the healthy muscle to beat again too soon. Rapid rhythm abnormalities can occur and negatively influence the function of the heart. This result to increase rate or volume of ventricular filling enabling us to hear a third heart sound.

Disruption of mid-sized atheromatous plaque due to injury or rupture would result to an injured but still living heart muscle which could still conduct electrical impulses slowly. Speed can become so slow that the spreading

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S4 heart sound √ impulse is preserved long enough for the uninjured muscle to complete its contraction. Slowed electrical signal still traveling within the injured area can re-enter and trigger the healthy muscle to beat again too soon. Rapid rhythm abnormalities can occur and diminished ventricular compliance. This may reduce the filling of the heart thus the fourth heart sound becomes audible.

Arrhythmia √

Upon the presence of abnormal heart sounds the myocardial cells are noted to be active but produce quivering instead of forceful rhythmic contractions. This prevents the heart from pumping blood effectively thus resulting to an abnormal intraventricular conduction leading to abnormal heart rate and rhythm.

Fever X

Obstruction of blood flow to certain parts of the heart allows the pyruvic acid to produce lactic acid that injures the myocardial tissue. It then releases cardiac enzymes that trigger the pyrogens which increases the temperature of the body.

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DOCTOR’S ORDERS

Date/Time Doctor’s Order Rationale Remark

November 12,2006

12:10 pm

• Admit under white service

• Low salt low fat diet

• Temperature, pulse, respiratory every hour and record

• Venoclysis

D5W 500cc x KVO rate

• Diagnostics:

Complete Blood Count

• Patient is admitted under the white service for close monitoring

• LSLF is ordered for patients with cardiac conditions to decrease the salt and fats that further aggravates the pt’s current condition

• Monitoring of TPR is done to detect any variation or changes from the normal range that would determine an abnormality in the patient’s condition

• It is an isotonic solution that is needed by our body to help regulate the body’s nutrients; it doesn’t swell or shrink the cell. Regulated only at the rate to maintain vein open for

emergency and IVTT meds

• Complete Blood Count offers

necessary information about the kinds and numbers of cells in the blood. This analyzes the 3 major types of cells in the body which are the

• Done

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Platelet

Random Blood Sugar

Creatinine Sodium, Potassium Chest x-ray Electrocardiogram Troponin T qualitative • Therapeutics Isosorbide Mononitrate (ISMN) 60mg/tab ½ tab OD

Isosorbide Dinirate (ISDN)

Red Blood Cell, White Blood Cell and Platelet • Blood test evaluates platelet production • Detects alterations in glucose metabolism • For evaluation of renal function • Evaluates fluid and electrolyte balance as well as renal or adrenal disorders • This identifies various abnormalities of the lungs and structures in the thorax Also used to identify localize fluid and air in the pleural cavity

• Used to screen for and diagnose a variety of cardiac conditions as well as abnormal heart rhythms, conduction

disturbance,

hypertrophy and other disorders

• Primarily ordered to determine if heart attack or other changes in the heart occurred

• ISMN is the treatment for anginal

• Done • Done • Done • Done • Not Done • Done • Done • Done • Done

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5mg/tab 1 tab now

Metoprolol 50mg/tab ½ tab BID

Captopril 25mg/tab ½ tab OD

Atorvastatin 80mg/tab 1 tab OD

Lactulose 30cc at HS

• Moderate High Back Rest

• Monitor intake and output

• O2 at 4Lpm via nasal cannula

• Hook to cardiac monitor

• Refer accordingly

attacks

• ISDN is the treatment for anginal attacks

• Treat hypertension, management of angina pectoris and prevention of MI

• Treat hypertension and reduce risk of developing congestive heart failure following MI

• Reduction of elevated total and LDL cholesterol and triglycerides • For chronic constipation • Lowers diaphragm, promoting chest expansion • Determine fluid and electrolyte balance and effectiveness of replacement • Help restore or improve breathing function and prevent damage to vital organs resulting from inadequate oxygen supply • Done • Done • Done • Done • Done • Done • Done • Done • Done

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12:30 pm

• Retrieve previous 2Decho result c/o

watcher and attach to chart

• Repeat ECG after 6 hours • Additional meds ASA 80mg/tab OD Clopidogrel 25mg/tab OD Enoxaparin 6000 IV every 12 hours Furosemide 40mg 1 tab OD Digoxin 0.25 mg/tab OD • Monitor the patients BP, CR and ECG reading • It is necessary to refer any unusualities to the physician prevent further complications

• Have a basis of the patient’s current situation base on the result of the previous laboratory exam

• For monitoring of any changes in the result

• Treatment of mild to moderate pain and prophylaxis of MI

• Reduction of atherosclerotic events in patients with atherosclerosis resulted from recent MI

• Prevention of deep vein thrombosis and pulmonary embolism

• Management of edema secondary to CHF and treatment of hypertension

• Used to slow the ventricular rate in tachyarrhythmias such as AF and atrial flutter • Done • Done • Done • Done • Done • Done • Done November

12, 2006 • To CCU •area for close Place in a special •

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8:30 pm _• Start O2 5Lpm per nasal cannula • Furosemide 40 mg IVTT now • Spironolactone 100 mg 1 tab now then OD • Refer monitoring • Counteracts potassium loss induced by other diuretics, for edema and hypertension • Done • Done • Done • Done November 13, 2006 (+) chest pain 10:35 am (+) Chest tightness O2 = 96 BP = 140/120 • Continue meds

• Complete bed rest without bathroom privilege

• Refer

• Give Isordil 5mg SL

• If not relieved by Isordil may give Tramadol 1 amp IVTT

• Give Isordil 5g SL now

• Start Isoket drip D5W 500cc + 1 amp Isoket to run out at 10cc/hr • Avoid valsalva maneuver • For Pro-time • Medication needs to be continued for continuity of treatment • Minimize the workload of the heart and promote rest

• Treatment of moderate to moderately severe pain • Treatment and prevention of angina pectoris attacks • Activities that require holding of breath and bearing down can result in bradycardia,

temporarily reduced cardiac output and rebound tachycardia with elevated BP.

• Screens for lack of coagulation factors necessary for blood clotting. Measures time required for a fibrin clot to form

• Done • Done • Done • Done • Done • Done • Done • Done • Done

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6:30 pm 7:30 pm 8:45 pm (+) chest pain • Activated Partial Thromboplastin Time • Refer • Isordil 5mg SL now

• Increase Isoket drip to 15cc/hr • Morphine 2mg IVTT now • Assess bleeding disorders or the effectiveness of heparin therapy by evaluating intrinsic coagulation factors necessary for blood clotting

• Management of severe pain,

pulmonary edema and pain associated with MI • Done • Done • Done • Done • Done November 14, 2006 100/64

• Repeat ECG 12 leads with long lead II

• Review of medicines 1. Spironolactone 25mg 1 tab OD 2. Digoxin 0.25 mg/tab OD 3. Carvedilol 6.25mg ½ tab OD 4. Captopril 25mg/tab OD 5. Atorvastatin 80 mg tab OD 6. ASA 80 mg 1 tab OD 7. Clopidogrel 75mg/tab OD 8. Enoxaparin 0.6ml SQ every 12

• Discontinue meds not in review of medicines • Refer • Treatment for essential hypertension and CHF • Done • Done • Done • Done November 15, 2006 10:20 am 98/61 I = 1085 O = 800 (-) chest pain (+) bowel • Continue meds • Refer • Done • Done

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movement November 16, 2006 2:50 am (+) chest pain 7:15 am still with occasional chest pain

• Give Isordil 5mg 1 tab SL now then PRN for chest pain

• Continue meds

• ISDN 5mg/tab SL PRN for chest pain

• Senna concentrate 2 tabs at HS • Refer • Treatment for constipation • Done • Done • Done • Done • Done November 17, 2006 9:30 am

• Diagnostics: repeat ECG 12 leads now

• Repeat Creatinine, Sodium, Potassium

• Continue all meds

• Refer accordingly • Done • Done • Done • Done November 18, 2006 (+) chest pain 125/98 • Diagnostics: repeat serum electrolyte • ISMN 60 mg ½ tab OD

• Continue all other meds

• Not Done • Done • Done November 19, 2006 8:30 am

• Resume Isoket drip (D5W 90cc + 1 amp Isoket) to run at 10cc/hr

• Continue other meds

• Refer • Done • Done • Done November 20, 2006 7:20 am 102/68 9:00 am (+) chills (+) dyspnea 130/100 O2 sat 97 Hgt 72 130/90

• Continue all meds

• Refer accordingly

• Continue Isoket drip

• Start Warfarin 5mg ½ tab OD

• For stat Complete blood count, Platelet count and Creatinine

• Referred due to dyspnea

• Diagnostics: • Prophylaxis and treatment of venous thrombosis, pulmonary embolism, AF with embolization and management MI • Determine blood • Done • Done • Done • Done • Done • Done

Case Presentation