Coronary Artery Disease and Heart Failure Scenario You are working in the intern

Question

Coronary Artery Disease and Heart Failure

Scenario
You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is
70-year-old J.M., a man who has been coming to the clinic for several years for management of coronary
artery disease (CAD) and hypertension (HTN). A cardiac catheterization done a year ago showed 50%
stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and
orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months.
On his last clinic visit 3 weeks ago, a chest x-ray (CXR) examination revealed cardiomegaly, and a 12-lead
electrocardiogram (ECG) showed sinus tachycardia with left bundle branch block (LBBB). You review J.M.'s
morning blood work and initial assessment.

Chart View
Laboratory Results
Chemistry
Sodium 142mEq/L
Chloride 95mEq/L
Potassium 3.9mEq/L
Creatinine 0.8mg/dL
Glucose 82mg/dL
BUN 19mg/dL
Complete Blood Count
WBC 5400/mm3
Hgb 11.5g/dL
Hct 37%
Platelets 229,000/mm3
Initial Assessment
Complains of increased fatigue and shortness of breath, especially with activity, and “waking up
gasping for breath” at night, for the past 2 days.
Vital Signs
Temperature 97.9° F (36.6° C)
Blood pressure (BP) 142/83mm Hg
Heart rate 105 beats//min
Respiratory rate 18 breaths/min

As you review these results, which ones are of possible concern, and why?

Knowing his history and seeing his condition this morning, what further questions are you
going to ask J.M. and his daughter?

CASE STUDY PROGRESS
J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and
has to lie down and rest (“put my feet up”) at least an hour twice a day. He has been sleeping on two
pillows for the past 2 weeks. He has not salted his food since the physician told him not to because of
his high blood pressure, but he admits having had ham and a small bag of salted peanuts 3 days ago.
He states that he stopped smoking 10 years ago. He denies having palpitations but has had a constant,
irritating, nonproductive cough lately

3. You think it's likely that J.M. has heart failure (HF). From his history, what do you identify as
probable causes for his HF?

4. You are now ready to do your physical assessment. For each potential assessment finding for
HF, indicate whether the finding indicates left-sided HF (L) or right-sided HF (R).
____. Fatigue, weakness, especially with activity
____ Jugular (neck) vein distention
____ Dependent edema (legs and sacrum)
____ Hacking cough, worse at night
____ Enlarged liver and spleen
____ Exertional dyspnea
____. Distended abdomen
____. Weight gain
___. S/S gallop
____. Crackles and wheezes in lungs

Chart View
Medication Orders
Enalapril (Vasotec) 10mg PO twice a day
Furosemide (Lasix) 20mg PO every morning
Carvedilol (Coreg) 6.25mg PO twice a day
Digoxin (Lanoxin) 0.5mg PO now, then 0.125mg PO daily
Potassium chloride (K-Dur) 10mEq tablet PO once a day

CASE STUDY PROGRESS
The physician confirms your suspicions and indicates that J.M. is experiencing symptoms of early leftsided
heart failure. A two-dimensional (2D) echocardiogram is ordered. Medication orders are written.

5. For each medication listed, identify its class and describe its purpose for the treatment of HF.

6. When you go to remove the medications from the automated dispensing machine, you see
that carvedilol (Coreg CR) is stocked. Will you give it to J.M.? Explain

7. As you remove the digoxin tablet from the automated medication dispensing machine, you
note that the dose on the tablet label is 250 mcg. How many tablets would you give

8. Based on the new medication orders, which blood test or tests should be monitored
carefully? Explain your answer.

9. When you give J.M. his medications, he looks at the potassium tablet, wrinkles his nose, and
tells you he “hates those horse pills.” He tells you a friend of his said he could eat bananas
instead. He says he would rather eat a banana every day than take one of those pills. How will
you respond?

10. The 2D echocardiogram shows that J.M.'s left ventricular ejection fraction (EF) is 49%.
Explain what this test results mean with regard to J.M.'s heart function.

CASE STUDY PROGRESS
This is J.M.'s first episode of significant HF. Before he leaves the clinic, you want to teach him about lifestyle
modifications he can make and monitoring techniques he can use to prevent or minimize future
problems.

11. List five suggestions you might make and the rationale for each

12. You tell J.M. that the combination of high-sodium foods he had during the past several days
might have contributed to his present episode of HF. He looks surprised. J.M. says, “But I
didn't add any salt to them!” To what health care professional could J.M. be referred to help
him understand how to prevent future crises? State your rationale.

13. You also include teaching about digoxin toxicity. When teaching J.M. about the signs and
symptoms of digoxin toxicity, which should be included? Select all that apply.
a. Dizziness when standing up
b. Visual changes
c. Loss of appetite or nausea
d. Increased urine output
e. Diarrhea

CASE STUDY OUTCOME
J.M.'s condition improves after 5 days of treatment, and he is discharged to home. He has a follow-up
appointment with a cardiologist in 2 weeks. He is enrolled in the clinic's STOP Heart Failure program, and
a heart failure nurse will contact him in a few days to check his progress.

Explanation / Answer

J.M was treated for cardiac artery disease(CAD). He had some problem related to hypotension, different issues associated to 2 main disases such assinus trachycardia, blockage of left bundle branch and many more. He was examined for those symptoms with appropriate test.

Hematocrit as well as Hemoglobin both are low, these results would show possible bleeding, that may cause anemia results in angina or Heart Failure symptoms. Low hemoglobin means reduced level of O2 saturation because hemoglobin carry oxygen throughout the body.

After knowing his history, i m going to ask:

What does your diet contains? body weight?
Is there any family history of HF? Do you consume alcohol in large amounts? Do you smoke?

3) unbalanced and unhealthy diet
Hx of CAD, Hypertension
Reduced haemoglobin and hemocrit
Increase in heart size

4) L Fatigue, weakness, especially with activity
R Jugular (neck) vein distention
R Dependent edema (legs and sacrum)
L Hacking cough, worse at night
R Enlarged liver and spleen
L Exertional dyspnea
R Distended abdomen
R Weight gain
L S/S gallop
L Crackles and wheezes in lungs

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