Triple Vessel Ischemic Heart Disease Treatment Case Nursing Essay

Triple Vessel Ischemic Heart Disease word Case Nursing EssayMr. MS is a 58-year-old Malay male who was previously diagnosed with hypertension, gout and triple vessel ischaemic heart unhealthiness. He offset presented with bureau painfulness in March 2010 where he was diagnosed with ischaemic heart dis order. He was unable to complete an exercise stress test and an angiogram done in Hospital Sultanah Aminah found him to have triple vessel disease. He was told angioplasty was not possible collectible to the severity of the blocks and was counseled for CABG but he was not keen. Meanwhile, he has had angina attacks 2 to 3 times per week every week since his initial diagnosis for the last 3 months, unremarkably relieved by sublingual GTN and was currently admitted for the 4th time for chest pain not relieved by GTN. ECG done 2 hours after aggression of chest pain showed ST economic crisis of 2mm at leads I, aVL, V3 V6 and left axis loss with no Q waves. Trop T was positive (2 .75 ng/ml) at 4 hours after onset and other cardiac enzymes were also raised signifi ejecttly. He was diagnosed with NSTEMI and treated with aspirin 300mg, IV morphine 2.5 mg, sublingual GTN 3 tablets and subcutaneous clexane 60mg BD for 3 days as well as continuing his current medicament regime of simvastatin, metoprolol, cardiprin, ISDN, amlodipine and GTN. interest admission, he was well in the ward with no recurrence of chest pain and did not pose any new complaints. He was dis forethoughtd after 3 days of inpatient treatment with instructions to attend his follow-up appointment at the cardio clinic in HSAJB on the 16th of June 2010 to make an appointment for surgery. Following this episode of chest pain, which he says is the worst so far, he is now quite keen for CABG.2) clinical HISTORYChief ComplaintChest pain for 1 day. account statement of Present IllnessMr. MS is a 58-year-old Malay male who was previously diagnosed with gout, hypertension and ischemic heart disease with triple vessel disease. He was awoken from sleep at about 10pm due to a central chest pain of fast onset. He described the character of the pain as crushing in nature and radiated to his tell apart. This episode of chest pain was the most severe since he was set-back diagnosed with ischemic heart disease. The pain was associated with profuse sweating, body weakness and was not relieved by rest. However, it was relieved by sublingual GTN, of which he has a yield of. His discomfort was made worst by exertion so he lay in bed to recover. Despite this, he had other episode of chest pain 30 minutes later. He took the sublingual GTN again but this time, the pain did not resolve. He was then brought to the emergency department of Hospital Batu Pahat by his son.This is Mr. MSs fourth admission for chest pain since March 2010. Since his diagnosis of ischemic heart disease in March, he has experience angina attacks two to tierce times per week, especially on exertion such as when strain ing while passing motion. During these attacks, he uses sublingual GTN to relieve his symptoms and normally feels much break down after that. He only comes to the hospital when GTN does not work to relieve his symptoms.Systemic ReviewMr. MS does not experience symptoms such as palpitations, dizziness, headache, nausea, vomiting, orthopnoea, paroxysmal nocturnal dyspnoea, epigastric pain, shortness of breath, fever, and had no syncopal episodes. He also does not have loss of appetite or loss of weight. intestine and urinary habits ar normal. His sleep has not been affected until this current episode whereby he was awoken by the chest pain.Past Medical HistoryMr. MS was diagnosed with hypertension 6 long time ago when he had an episode of headache. He has been on medical specialty since and was on regular follow-up with KK Rengit. He was diagnosed with gout 5 years ago when he had a left big toe swelling which resolved after some medication. He is not on long term medication for g out. Mr. MS was admitted for the first time 5 years ago in 2005 when he had bilateral renal calculi. He was subsequently referred to Hospital Sultanah Aminah for further management of this line of work and it has since resolved and does not have follow-up anymore.Mr. MS was diagnosed with ischemic heart disease in March 2010 when he presented with chest pain for the first time. Following his recovery, he underwent a stress test in Hospital Batu Pahat but according to him, was unable to complete the procedure due to chest discomfort. He was referred to the cardiology building block in Hospital Sultanah Aminah for further management where an angiogram was performed and he was told to have triple vessel disease. He was also told that angioplasty was not possible due to the severity of the blocks. He was recommended to have Coronary Artery Bypass Grafting (CABG) but as of yet, no appointment has been made as he was still unsure of termination through with the procedure. Following thi s episode of chest pain, Mr. MS has decided that going for the CABG is the only thing that will keep him alive.His current medications include contraceptive pill Simvastatin 20mg ODTab Metoprolol 75mg BDTab Cardiprin 100mg ODTab Isosorbide Dinitrate (ISDN) 5mg TDSTab Amlodipine 10mg ODSublingual Glyceryl Trinitrate (GTN) PRNHe is compliant to his medication regime.Mr. MS is not known to have diabetes or hyper lipoidemia. He also does not have any known food or drug allergies.Family HistoryMr. MS is the 3rd of 9 siblings. His father had hypertension and passed away a long time ago due to unknown causes. His mother and other siblings argon healthy. None of them have hypertension, diabetes, ischemic heart disease or malignancy.Social HistoryHe lives in a kampung in Rengit with his wife and 5 children. Mr. MS does not smoke nor consume alcohol. He works in a palm oil plantation. The distance from his house to Hospital Batu Pahat is about half an hour. On further enquiry, Mr. MS says tha t the cost of the CABG is about RM1000, which he can afford.3) FINDINGS ON CLINICAL EXAMINATION(Mr. MS was examined by me 9 hours after onset of chest pain)Mr. MS was alert, conscious, and communicative. He was not in obvious pain or respiratory distress. He was lying down comfortably on his bed. in that respect were no tendon xanthomata, xanthelasma, pallor, corneal arcus or pedal edema. His JVP was not raised. His clinical parameters areBlood Pressure 158/94 mmHgHeart Rate 94 beats per minute. Regular rhythmRespiratory Rate 20 breaths per minuteTemperature 37CSpO2 97% under room airOn scrutiny of the precordium, the apex beat was located at the 5th intercostal space on the midclavicular line and was normal in character. Parasternal heave was not felt and in that location were no thrills. First and second heart sounds were heard. There were no murmurs or added heart sounds.On examination of the chest, there was no deformity and chest amplification was equal on both sides. P ercussion and tactile vocal fremitus was normal and equal on both sides. On auscultation, vesicular breath sounds were heard end-to-end all lung fields with good air entry. There was no wheezing or crepitations heard.On examination of the abdomen, it was soft and non-tender. There were no masses felt. Bowel sounds were heard and normal.4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONINGProvisional diagnosingAcute myocardial infarction with underlying triple vessel ischemic heart disease and hypertensionWith a history of diagnosed triple vessel ischemic heart disease with multiple episodes of angina attacks since the initial diagnosis, it is highly likely that Mr. MS is presenting with an crisp coronary particular and this should be a priority until proven otherwise. This is evidenced by the presentation of central, crushing chest pain of sudden onset that radiated to the neck and associated with profuse sweating and body weakness which is classical of a myocardial infarction . Mr. MS will collect immediate investigations such as an electrocardiogram and cardiac enzymes to differentiate the acute coronary syndromes so that the appropriate management may be instituted for him e.g. if he has an ST-segment elevation myocardial infarction (STEMI), he will require myocardium-saving thrombolytic therapy to disrupt the ischemic event. As Mr. MS did not present with features such as acute shortness of breath, loss of consciousness and severe palpitations, it seems that he does not have complications of acute myocardial infarction but these developments should be watched out for throughout his admission as complications may arise later.Differential DiagnosisPulmonary embolismPulmonary embolism is a possibility that can be considered when a patient presents with an acute chest pain that is accompanied by shortness of breath, hemoptysis, tachypnea, fever and even cyanosis and collapse in severe cases. Furthermore, the chest pain is of a pleuritic nature, of which it is worsened on breathing, and a pleural rub can be heard on auscultation of the chest. However, Mr. MS did not present in such a way. At the same time, Mr. MS did not have try factors such as a deep vein thrombosis, prolonged immobilization or recent surgery. It is still highly likely that Mr. MS has suffered an acute myocardial infarction, and an ECG would help to differentiate between the two as pulmonary embolism might show the classic S1Q3T3 pattern of right axis deviation or right bundle branch block. Either way, the diagnosis should be made quickly so treatment may be instituted before his peg down becomes worse or complications develop.Aortic dissectionAortic dissection presents as an acute onset chest pain that is tearing in nature, and often radiates to the back. It is often confused with myocardial infarction due to its presentation but differences include the pretermit of profuse sweating, signs of heart pump dysfunction and a normal ECG. Risk factors are usually un controlled hypertension, connective tissue disorders or chest trauma. Mr. MS has hypertension, but is under control, and does not have the other risk factors. A diagnosis of myocardial infarction should be the priority as thrombolytic therapy is vital, but if there is any reason to doubt that diagnosis, then further investigations should be performed.5) IDENTIFY AND grade THE PROBLEMS1. Acute chest painMr. MS has acute chest pain with features very suggestive of a classical picture of myocardial infarction as he presents with crushing central chest pain that radiates to the neck and associated with profuse sweating and weakness. Given that he is known to have triple vessel ischemic heart disease and that he has suffered some(prenominal) angina attacks since his initial diagnosis, it is highly likely that he is having an acute myocardial infarction. Without further a due, he take an electrocardiogram (ECG) and cardiac enzymes tested to distinguish between the different acute coron ary syndromes so that the appropriate treatment protocols may be initiated for him as before long as possible to disrupt the ongoing ischemia. As Mr. MS is having severe chest pain that may overstimulate his sympathetic system and cause further ischemia, he will require immediate supportive therapy such as effective pain medication and oxygen therapy.2. Triple vessel ischemic heart disease awaiting CABGMr. MS was diagnosed with triple vessel ischemic heart disease when he first presented with chest pain in March 2010 and has since experienced many episodes of angina. Given his diagnosis and disease pattern, he is at a very high risk of developing a severe acute coronary event that may prove fatal if the infarction is too extensive or if complications develop. As percutaneous revascularization with a stent or balloon was not possible for him, he will require a CABG to both relieve his symptoms and reduce his mortality risks in the long term. He was unsure of going ahead with the fe at previously, therefore no appointment date was given for surgery. However, now that he has changed his mind, every effort should be made by both the doctors in charge of him here in Hospital Batu Pahat and in the cardiology unit of Hospital Sultanah Aminah to arrange for his surgery as soon as possible, given the circumstances of his condition.3. Compliance to medicationMr. MS is on several medications for his triple vessel ischemic heart disease and will require revascularization surgery soon in order to ebb his mortality risks. However, waiting for a CABG in the government setting may take some time, even under dire circumstances due to the nature of the system. Therefore, it is extremely crucial that Mr. MS is compliant to his medication regime while awaiting a CABG to prevent another episode of infarction. He should be counseled to fully understand this and the situation of his ischemic heart disease. It is also the responsibility of his doctors to ensure that he is taking th e right combination of medications with the aim to prevent another acute cardiac event. Meanwhile, a sufficient supply of sublingual GTN should be provided for Mr. MS in cases of angina attacks at home. He should come to the hospital at once if GTN fails to relieve his symptoms.4. Regular screening for comorbid diseasesMr. MS has not been diagnosed with diabetes or hyperlipidemia previously but these diseases are strong risk factors for the long term implications of his ischemic heart disease. Therefore, Mr. MS should be screened regularly e.g. twice yearly during his follow-up appointments. Early detection of diabetes is necessary so that treatment can start as soon as detected in order to prevent his ischemic heart disease from becoming worst than it already is. As for his lipid control, if his lipid profile is found to be outside the normal limits, the dosage of his medication can be increased as necessary. Following his CABG, he will film to maintain a healthy lifestyle of a g ood, well-balanced, low-salt and low-fat diet and regular exercise within his limits.6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS1. Electrocardiogram (ECG)To tang for any changes that may indicate an ongoing ischemic event, such as ST elevation or depression and T wave inversion in order to support the diagnosis of an acute myocardial infarction so appropriate treatment can be started. Differentiation of ST segment elevation or depression is also crucial in initiating treatment as thrombolytic therapy is only indicated for ST-elevation myocardial infarction.Results ECG on admission (2 hours after onset) shows sinus rhythm with ST depression at leads I, aVL, V3 V6 with left axis deviation. T wave was present and normal.Interpretation The ST depression in the leads above indicate an ischemic event at the anterolateral sections of the heart. The lack of ST elevation concludes a diagnosis of either unstable angina or NSTEMI, depending on the levels of cardiac enzymes. There is no sign of old infarction.2. Cardiac EnzymesTo behavior for elevated levels of cardiac enzymes such as troponin T, creatinine kinase (CK), lactate dehydrogenase (LDH) and aspartate transaminase (AST) that will indicate myocardium ischemia and necrosis. If elevated, a diagnosis of NSTEMI can be made in accordance with the ECG changes. However, cardiac enzymes when done too early after onset may not show any rise in levels 1. This does not mean that necrosis has not taken place and the test should be repeated once more at 6 hours after onset 1.Results Troponin T (4 hours after onset) 2.75ng/ml (12 hours after onset) (60 hours after onset) Normal Range (U/L)CK 997 263