Case Study: Initial history 40-year-old male complaining of substernal chest pai

Question

Case Study:

Initial history

40-year-old male complaining of substernal chest pain that began approximately 30 minutes

Before he came to the emergency department

Pain has eased slightly but is still present, was 8/10 in severity, now 5/10

Additional history

Also feels pain in his left shoulder

Feels short of breath and somewhat sick to his stomach, but has not vomited

Denies coughing, fever, or change in the nature of the pain with deep breathing

40pack/year history of smoking

Blood pressure has been a little elevated (148/92mmHg) on his last two vistis to his nurse practitioner

Eats a lot of fatty foods but says his total cholesterol doesn’t change no matter what he eats; it was 242mg/dL last month

Father has angina that began at age 53

Denies diabetes

Exercises regularly and has not gained weight

Says he has had a couple of episodes of shortness of breath while jogging but attributed it to “growing old”

Has never been hospitalized except for one case of influenza complicated by pneumonia 3 years ago

Perceives himself as very healthy, is on no medications, and has no known allergies

Physical Examination

Alert, moderately anxious man in mild distress.

T=37 orally, P=100 with occasional premature beat, RR=24, BP=160/98 in both arms (sitting).

Skin warim and disphoretic without cyanosis

PERRLA, fundi benign, pharynx clear

Neck supple withour thyromegaly, adenopathy, or bruits

<2cm jugular venous distention

Tachypneic, mild use of accessory muscle of respoiration

No tenderness upon palpation of the chest wall

No dullness to precussion

Slight inspiratory crachles (rales) heard at both bases without egophony

No Rubs

Abdomen with bowel sounds heard throughout, no organomegaly or tenderness, no bruits, rectal guaiac negative

Extremities with full and symmetric pulses; slight bruit over left femoral artery, no pedal edema

Alter and oriented, neurologic examination intact to cognition, strength, sensation, gait, and deep tendon reflexes.

Diagnostic results

ECG shows 4mm ST elevation with T-wave inversion in the anterior precordial leads with occasional premature ventricular contraction

Oximetry shows oxygen saturation of 95%

Chest radiograph with borderline cardiomegaly and mild pulmonary congestion without acute infiltrates or pleural disease and no widening of the mediastinum.

Electrolytes and CBC normal

PT and PTT normal

CPK-MB normal

Troponin I normal

Please explain, what should I recommend as a nurse for the diagnosis of this patient?

Explanation / Answer

By observing the symptoms and signs of patient we can conclude as he is suffering from myocardial pathology. He had a positive family history of angina, as a nurse first give advice to the patient to decrease salt and fat intake as they may precipitate and aggrevate his condition and also give advice to stop smoking as a preventive measure, if his condition does not subside then keep him on medication with calcium channel blocker or angiotensin converting enzyme inhibitors or angiotensin receptor blocker or vasodilators or diuretics or best medication is using beta blockers. Advice him to consult doctor if his condition does not subside and become normal. The main moto is to decrease word load on heart and increase myocardial blood flow or blood perfusion to prevent myocardial infraction, if his condition is severe then put on mechanical ventilation with humidified oxygen as it reduses the work of heart in respiration, as a nurse you should advice to decrease and stop cigarette smoking as it is a major risk factor and low salt diet intake, decrease fat rich food intake, advice to do regular exercise, lifestyle changes to reduce sedentary lifestyle, continue on medication and advice to come for regular checkups and bp monitaring regularly.

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