Question

F.M. is a 68-year-old white man who comes to the emergency department (ED) in the early afternoon with a 2-day history of severe chest pain. The pain started on wakening the previous day. The pain increased during the night, but his wife could not convince him to go to the hospital. He comes to the ED today because the pain is severe and no longer relieved by rest.

Subjective Data

• Describes recurring chest pain for the past 6 months that was relieved by rest; the pain is a feeling of heaviness in the chest with no radiating pain to arm or jaw or accompanying complaints of nausea or dizziness.
• Recently the chest pain has become severe and is no longer relieved by rest; is now complaining of being slightly nauseated.
• His father died of a heart attack at age 62.
• Smokes one pack of cigarettes per day for over 30 years.
• Describes his lifestyle as sedentary

Objective Data - Physical E x a m

• Blood pressure 180/96, pulse 98, respirations 20, Height 5’11”, weight 270 lbs
• Skin diaphoretic and clammy
• He appears anxious

Diagnostic Studies

• Chemistry panel is normal
• "Cardiac markers" lab results are pending
• Electrocardiogram showing changes that correlate with non–ST-segment–elevation myocardial infarction (NSTEMI)

Interprofessional Care

• Nitroglycerin was given and it relieves his chest pain

Discussion Questions

(I already answered the first two questions)

3. What could be a possible "trigger event" for the NSTEMI? Explain the pathophysiology of how it can cause a myocardial infarction.

4. What diagnostic studies are indicated for F.M.? Do you suspect the Troponin results will be normal, low, or elevated - and why?

Ongoing Case Study.

F. M is receiving treatment for his myocardial infarction and is progressing well, F.M tells the nurse following morning “I can’t breathe” the nurse notices that F. M is sitting in a tripod position and has a productive cough. His breath sounds are diminished with prolonged expiration, and his respirations are labored.

5. What in F.M.’s history is commonly associated with COPD?

6. Compare and Contrast Chronic Bronchitis and Emphysema.

7. What other clinical manifestations are associated with COPD??

Answer 1

3- vigrous physical exertion anger can be two possible"trigger event" for NSTEMI.

pathophysiology of miocardial infarction -

• Myocardial ischemia results from decreased myocardial oxygen supply and/or increased demand. In the majority of cases, NSTEMI is due to a sudden decrease in blood supply via partial occlusion of the affected vessel. In some cases, markedly increased myocardial oxygen demand may lead to NSTEMI (demand ischemia), as seen in severe anemia, hypertensive crisis, acute decompensated HF, surgery, or any other significant physiologic stressor.
• UA/NSTEMI most often represents severe coronary artery narrowing or acute atherosclerotic plaque rupture/erosion and superimposed thrombus formation. Alternatively, it may also be due to progressive mechanical obstruction from advancing atherosclerotic disease, in-stent restenosis, or bypass graft disease.
• Plaque rupture may be triggered by local and/or systemic inflammation as well as shear stress. Rupture allows exposure of lipid-rich subendothelial components to circulating platelets and inflammatory cells, serving as a potent substrate for thrombus formation. A thin fibrous cap (thin-cap fibroatheroma) is felt to be more vulnerable to rupture and is most frequently represented as only moderate stenosis on angiography.
• Less common causes include dynamic obstruction of the coronary artery due to vasospasm coronary artery dissection (more common in women), coronary vasculitis, and embolus.

4- NSTEMI is diagnosed through a blood test and an ECG. The blood test will show elevated levels of creatine kinase-myocardial band (CK-MB), troponin I, and troponin T. These markers are evidence of possible damage to the heart cells.

The ECG tracing can have multiple abnormalities, but, by definition, there is no ST segment elevation. The most common finding is ST segment depression.

5- Breathing difficulties and productive cough in the history of F.M. is associated with COPD.

6- Emphysema is a lung condition where the air sacs or alveoli become damaged. These air sacs supply oxygen to the blood, so when they are damaged, less oxygen enter the blood.

symptoms of emphysema-

• Frequent coughing or wheezing.
• A cough that produces a lot mucus.
• Shortness of breath, especially with physical activity.
• A whistling or squeaky sound when person breathe.

Bronchitis- is an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs. People who have bronchitis often cough up thickened mucus, which can be discolored. Bronchitis may be either acute or chronic.

7 - symotoms of copd include-

• Shortness of breath, especially during physical activities
• Wheezing
• Chest tightness
• A chronic cough that may produce mucus (sputum) that may be clear, white, yellow or greenish
• Frequent respiratory infections
• Lack of energy
• Unintended weight loss (in later stages)
• Swelling in ankles, feet or legs
• Exacerbations when symptoms worsen.