coronary artery disease - Nursing Case Study

Pathophysiology

• Primary mechanism: Atherosclerosis - fatty deposits build-up on the inner walls of the coronary arteries, reducing blood flow to the heart. These plaques can rupture, causing a clot to form which can further block blood flow.

• Secondary mechanism: Endothelial dysfunction - the innermost layer of the artery can become damaged (due to factors like smoking or high blood pressure), impairing its ability to relax and contract. This can contribute to the narrowing of the arteries.

• Key complication: Myocardial infarction (heart attack) - if a clot blocks blood flow completely, part of the heart muscle is deprived of oxygen, causing tissue death and potentially leading to a heart attack.

Patient Profile

Demographics:

62-year-old male, retired engineer

History:

• Key past medical history: mild hypertension, occasional high cholesterol

• Current medications: Lisinopril for hypertension, over-the-counter low-dose aspirin

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Mild discomfort in chest during physical activity

• Key symptoms: Shortness of breath during exertion, occasional chest discomfort

• Vital signs: Blood pressure 130/82 mmHg, pulse 75 bpm, respiratory rate 16 breaths per minute, temperature 98.6 F, oxygen saturation 98% on room air

Section 1

Initial Assessment Findings:

Upon further examination, the patient's discomfort in the chest was localized to the left side and was described as a dull ache that increased with physical activity. It was not accompanied by any other symptoms such as nausea, diaphoresis, or dizziness. The patient's skin was cool and dry, and his color was normal. Cardiac auscultation revealed normal heart sounds with no murmurs or gallops. His lungs were clear bilaterally. His peripheral pulses were palpable with normal rate, rhythm, and amplitude.

The patient's EKG showed normal sinus rhythm with no ST elevations or depressions, and no T wave inversions. His chest X-ray was unremarkable. His lipid profile revealed total cholesterol of 205 mg/dL, HDL cholesterol of 40 mg/dL, LDL cholesterol of 130 mg/dL, and triglycerides of 150 mg/dL. His fasting blood glucose was 95 mg/dL.

These findings suggested that the patient's symptoms were likely due to stable angina, a type of chest pain caused by reduced blood flow to the heart muscle. This condition is often triggered by physical exertion and relieved by rest or medication. Management would typically involve lifestyle changes, medications, and potentially procedures to improve blood flow. The patient was advised to avoid strenuous physical activity until further evaluation could be conducted.

Section 2

New Diagnostic Results:

A few days later, the patient was brought in for a stress test to further evaluate his cardiac function. The patient was asked to walk on a treadmill, gradually increasing the intensity of the exercise. During the test, the patient again experienced left-sided chest discomfort after about ten minutes of exercise. His blood pressure increased from a resting 130/80 mmHg to 150/90 mmHg during the peak of the exercise. His heart rate increased from a resting 72 bpm to 110 bpm during peak exercise. The EKG showed no ST-segment changes, but there was a noticeable decrease in the amplitude of the T waves during the peak of the exercise which normalized during recovery.

The findings from the stress test suggested that the patient's heart may not be getting enough oxygen during periods of increased physical activity, consistent with the initial diagnosis of stable angina. The patient was advised to continue avoiding strenuous activity until a treatment plan could be established. The treatment plan would likely involve medications such as beta-blockers or calcium channel blockers to reduce the heart's demand for oxygen, and lifestyle changes to manage his slightly elevated cholesterol levels.

Section 3

New Complications:

Over the next couple of days, the patient reported occasional episodes of mild chest discomfort, particularly when he was carrying heavy objects or climbing stairs. He also noticed that he was becoming short of breath more easily than before, even during light activities such as walking around his house. His blood pressure readings at home ranged from 132/82 mmHg to 138/88 mmHg, and his resting heart rate was consistently around 75 bpm.

Although these symptoms were relatively minor, they suggested that his coronary artery disease might be progressing faster than expected. The patient was advised to monitor his symptoms closely and to report any significant changes immediately. The healthcare team also recommended that he should start taking a low dose of a beta-blocker to help reduce his heart's oxygen demand, along with a statin to help lower his cholesterol levels. The patient was scheduled for a follow-up appointment in one week to evaluate the effectiveness of the new medications and to discuss any needed adjustments to his treatment plan. The team reiterated the importance of lifestyle modifications, including maintaining a heart-healthy diet, engaging in regular light physical activity, and avoiding smoking and excessive alcohol.

Section 4

Response to Interventions:

At the follow-up appointment one week later, the patient reported that his chest discomfort had reduced significantly and he was able to carry out light activities without feeling short of breath. His blood pressure readings at home had also improved, averaging around 128/78 mmHg and his resting heart rate was maintained at 70 bpm. The effectiveness of the beta-blocker in reducing his heart's oxygen demand and the statin in lowering his cholesterol levels was evident.

However, he also mentioned feeling slightly dizzy at times, especially when standing up too quickly. This is a common side effect of beta-blockers due to a reduction in blood pressure. The healthcare team advised him to rise slowly from a sitting or lying position to prevent these dizzy spells. The team also advised him to continue with his lifestyle modifications and to return for another follow-up in a month's time. A lipid profile test was also scheduled to evaluate the effectiveness of the statin therapy. The patient was reminded to continue monitoring his symptoms and to report any significant changes immediately.

Section 5

Change in Patient Status:

At the one-month follow-up, the patient reported a further reduction in chest discomfort and no incidents of dizziness. He now performs daily walks and has started a low-fat, low-sodium diet. His blood pressure readings at home continue to be stable, averaging 130/80 mmHg with a resting heart rate consistently around 68 bpm. He reported some minor side effects from the statin therapy, such as mild constipation, but over-the-counter fiber supplements have been helping.

However, he also noted some new symptoms. He reported occasional bouts of nocturnal sweating and a decrease in appetite leading to a weight loss of approximately 4 pounds over the last month. These symptoms could indicate a potential underlying issue. The healthcare team advised him to monitor these symptoms closely. They scheduled a complete blood count (CBC) and thyroid function test to rule out possible causes such as infection or hyperthyroidism. The team reminded him to continue his lifestyle modifications and medications, emphasizing the importance of maintaining a balanced diet despite his reduced appetite.