Question

Scenario 1:

It is midmorning on the cardiac unit where you work, and you are getting a new patient. G.P. is a 60-yr old retired businessman, who is married and has 3 grown children. As you take his health history, he tells you that he began feeling changes in his heart rhythm about 10 days ago. He has hypertension (HTN) and a 5-yr history of angina pectoris. During the past week, he has had frequent episodes of mid-chest discomfort. The chest pain has awakened him from sleep but does not go away when he takes nitroglycerin (NTG), which he has been taking sublingually (SL) about 8-10 times over the past week. During the week, he has also experienced increased fatigue. He states, “I just feel crappy all the time”. A cardiac catheterization procedure several years ago revealed 50% stenosis of the right coronary artery (RCA) and 50% stenosis of the left anterior descending coronary artery. He takes amlodipine, metoprolol, atorvastatin (Lipitor), and baby aspirin 81mg/day.

1. What other information are you going to ask G.P. about his episodes of chest pain? Why is this important?

2. what are common sites for radiatjon of ischemic cardiac pain?

3. You know that G.P has atherosclerosis of the coronary arteries. Explain this condition, and why it is important to deal with before it progresses.

4. G.P has not told you about his risk factors, and you need to know his risk factors for coronary artery disease in order to plan teaching for lifestyle modification. what will you need to ask him about ?

Answer 1

1. I will ask the patient that whether he have uncomfortable pressure or fullness on chest or have squeezing chest pain lasting some more time. Or the pain worsens if he do some activities or excersice.

Reason for knowing this symptoms is to know that is the patient is at unhealthy cholestrol levels which can further lead to atherosclerosis and then to cardiac attacks.

Whether he e experience shortness of breath, sweatting, dizziness or fainting. The reason is that to know if there is any fluctuation in his heart rate or bloo d blood pressure level. Also to know whether he is at risk of pulmonory embolism.

Radiating pain beyond the chest to both arm is a risk factor of attack which has to be monitored.

2. The actual location of the pain is from a specific spot but rather throughout the chest. The chest pain due to the cardiac ischemia may spread into various upper body parts. If the pain is on right or left side but not the centre then he is not at risk of ischemia. The radiating chest pain may spread to neck, throat, lower jaw, teeth, shoulders and arms.Sometimes the radiating pist, fingers or behind the shoulder. Ischemic pain may worse over time.

3. Atherosclerosis of coronory artery is a condition in which the plaques get deposited into the arteries and the arteries becomes narrowed. So the blood supplies to the heart and body tisssues get affected. The plaque may be due to the deposition of cholestrol, macrophages etc. The plaques may grow further leading to many complications like strokes and heart attacks.

Atherosclerosis should be treated befer it progress further. As the plaque devolops the arteries get further narrowed and the blood supply get blocked leading to cardiac attack. The plaque should be identified by various tests including angiogram, CT scan, MRA etc.

The condition become worsens if the plaque reptures. Because the blood may get clot inside the artery leading to attack and also in the brain it may lead to stroke.

4. Inorder to teach a life style modification to GP i would like to know the following facts from him.

Whether he smoke or not. Because those who smokes are at higher risk of having coronory heart disease.

To know, did he controlls his blood pressure levels, or the kinds of food he takes or avoid inorder to control the blood pressure levels.

How carefull is he about his blood cholestrol levels. What kind of diet he follow to mange the cholestrols levels. Whether he concers about his body weight because overweight or obeisity can worsens the risk of disease.

Is there any unrelieved stress happening in his life. Stress is one of the important risk factor.

Is there any high amount of saturated fats, sugars, trans fats he is consuming which is the thing that worsens the condition