Question

Kevin, a 65-year-old male, presents to the office with chest pain complaints on inspiration and shortness of breath(SOB). He states that the chest pain began about 12 hours ago and feels like a sharp pain in the center of his chest. When the pain began, he immediately took aspirin and then went to bed. When he woke up this morning, the pain was still there. Although not as intense.

The patient’s medical history includes nephrolithiasis and gastroesophageal reflux disease.

Social history includes that patient is an everyday smoker, 1 pack per day starting at age 16. He admits to consuming 2-3 beers per night.

He takes as needed antacids and has no drug allergies.

Family history includes a father who died at age 59 of myocardial infarction (MI) and a brother with Type 2 Diabetes Mellitus.

BP is 116/74, Pulse 80, Respiratory rate 14, Temperature 98.6 F oral.

Now you have identified your “working diagnosis.” Use this diagnosis to answer the following questions.

1: What risk factors put this pt at risk for the DX?

2: Specifically, how will the pt present clinically to support your DX. (HPI)

3: Consider PMH, Social, and Family Hx, will any of this influence or support your working Dx? If so, explain.

4: What physical assessment of the systems will you perform based on your working DX

5: What labs, studies, etc. will you order to support your Dx

6: Using approved guidelines, how would you treat this patient? Be specific: Medications you would order, strength, frequency, length of treatment.

Why did you choose one treatment over another? Are there any contraindications?

7: What type of education will the patient require about the DX and management of the DX?

8: What is your follow up plan for the patient?

Answer 1

1. The major risk factors are, the patient is a chronic smoker as he started smoking since the age of 16 and smokes one packet of cigarette everyday.

• Next one is he consumes 2 - 3 beers every night.

2. The patient is having chest pain on inspiration and has shortness of breath.

• The type of pain is like sharp pain in the centre of his chest and it is not relieved after taking aspirin.

3. The patient's past medical history (PMH), social and family history has got a major influence in the working diagnosis.

• Client's chronic smoking and drinking habit, nephrolithiasis (kidney stones) which occurs as a result of smoking, gastroesophageal reflux disease may be due to loss of his stomach muscle tone.
• Also his father died at the age of 59 due to Myocardial infarction (MI).
• These all factors has strong influence in development of this disease in him.

4. In this case, physical assessment includes complete cardiac monitoring which includes,

• BP
• Heart rate
• Respiratory rate
• SpO2 (oxygen saturation )
• ECG monitoring
• Holter monitoring - it is a 24 hour monitoring test to check for any cardiac arrhythmias.
• Coronary angiogram is needed only if any suspected artery block is there.

5. Lab studies include,

• Complete blood count ( CBC)
• PT/INR/aPTT
• BT/CT (bleeding time and clotting time)
• Cardiac enzymes ( CK, CKMB, Troponin I)
• SGPT, SGOT
• Serum sodium, potassium, creatinine.
• BUN ( Blood Urea Nitrogen ).
• Urine analysis.

7. The patient education regarding the diagnosis and management includes advice him,

• to control smoking by reducing the number of cigarettes per day and try to stop smoking by this method.
• to control his drinking habit too by reducing the amount to be taken every day.
• to prevent heavy lifting of objects to prevent chest pain.
• to carry the necessary drugs to be used wherever he goes.
• to carry a card with him explaining that he is a patient taking aspirin like tablets and has heart disease. This could be useful for anyone with him to help him if any emergency occurs.
• to avoid passive smoking.
• to control diet which has high levels of fat or cholesterol.
• to drink 2-3 litres of water a day to maintain good hydration and feeling of well.
• not to discontinue any drugs unless and untill the doctor advised him to do so.

8. Follow up can be done after one month or whenever any emergency occurs.

• Every month follow up is necessary to check whether the cardiac parameters are normal or not.
• During follow up the doctor may change the dose of prescribed drugs if he feels that the values are normal.
• Regular check up is needed to note the prognosis of the disease.

Note : Myocardial infarction is a disease which occur due to the blockage in the coronary arteries which supply the heart. The major cause of this disease is smoking so one should control smoking than depending on drugs.