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Mr. Kevin Heart is a construction worker who lives with his wife and 3 children 17, 14, and 12 year old boys. Although his wife works part time Mr. Heart is the family’s main source of income. They currently live in the low-income and urbane side of the city. Mr. Heart’s primary concern is to keep his kids out of the streets so he is working extra hours at work to be able to afford to move out of their current residency to a safer area and to afford paying for his kids’ basketball teams to keep them off the streets. Consequently this is very stressful for him which leads him to not pay much attention to his health and he continues to smoke as a coping mechanism. However, he greatly cares for his kids and is passionate about basketball and currently coaches his eldest son’s basketball team. The whole family is at the championship basketball game when suddenly…

Who is patient Kevin Heart?

Patient Kevin Heart is a 55 year old African American male with a history of insulin dependent diabetes type II, hypertension, smokes 20 cigarettes daily, and atherosclerotic peripheral vascular disease . Patient Kevin Heart is seen at an outlying hospital awith complaint of chest pain and shortness of breath soon after his son’s basketball game approximately 30 minutes ago. Initially he was hesitant to visit the clinic however, his children convinced him to come since further questioning revealed that he had been having more frequent episodes of chest pain for the past week accompanied with shortness of breath.

What orders do you expect? And why?

Initial orders:

● > 2 L oxygen via nasal cannula- Part of core measure

● IV insertion and maintenance fluids normal saline- Have immediate access for future

medication administration

● Cardiac monitor → showed normal sinus rhythm without ectopy

● 12 lead ECG → To rule out ST elevation MI

● Cardiac enzyme labs Q6H for 24 hours → This will confirm cardiac damage and will rule out NSTEMI-MI if ECG does not result in an ST elevation

What treatment do you expect? Why?

• Morphine: decreases oxygen demand and provides analgesia
• Oxygen: Restore perfusion to vital organs
• Nitroglycerin: vasodilation to restore perfusion and prevent second ischemic event
• Aspirin: Antiplatelet action prevents a second ischemic event
• STEMI protocol

○ PCI (percutaneous intervention) in 90 minutes or less

What is the order in which you provide the core measures?

1. Oxygen

2. Aspirin

3. Morphine

4. Nitroglycerin

Patient Kevin Heart experienced recurrent pain that was not eased with three nitroglycerin (NTG) tablets, diaphoresis, and profound shortness of breath requiring intubation . Patient was admitted to the coronary care unit to rule out myocardial infarction.

Assessment:

Respiratory: Patient complains of dyspnea and increased work of breathing. Respirations 32 and shallow. O2 saturation is 88% on 5 liters

Cardiovascular: S1/S2 present. Rapid pulse. 1+ radial pulses, weak pedal pulses. Capillary refill 5 seconds. No signs of clubbing. Skin cool and diaphoretic.

Neuro: Oriented x4. Agitated. Pupils are equally round and reactive to light. Grip strong bilaterally.

GI: Patient is nauseous and had small emesis x1

GU: WNL

Integumentary: Skin break down on left toe

Musculoskeletal: WNL

Diagnostic data at admission:

Vitals:

● BP 190/94

● HR 106

● RR 32

● O2: 88%

● T: 36.7

Labs:

● Cl 1.8 L/min/m2

● Troponin I 5.3 mg/L

CK 350 U/L

● CK-MB 5.8 %

● LDH 680 U/L

● AST 52 U/L

● Myoglobin 125 ng/L

ECG revealed ST- segment elevation in leads V2 and V3.

Cardiac catheterization revealed the following :

● Ejection fraction of 45%

● 85% obstruction of left anterior descending coronary artery

● 90% to 95% obstruction of the circumflex artery

● 80% of obstruction of the right coronary artery

Treatment:

● Stent in place via radial artery.

● HTN meds

● Patient education

● Modes of lowering cholesterol

● Smoking cessation

Open Ended Questions:

1. What information would you make sure to include in your patient education?

a. Exercise and diet

b. Strict medication adherence

c. Diabetic care (foot care)

d. Smoking cessation support/resources

2. How would you educate on discharge medications for this patient?

a. Antiplatelets: Aspirin, clopidogrel (Plavix), warfarin (Coumadin),

b. Beta-blockers

c. ACE-Inhibitors

d. Statins

3. When should Mr. Kevin Heart call his health care provider?

a. Pain, pressure, tightness, or heaviness in the chest, arm, neck, or jaw

b. Shortness of breath

c. Numbness in arms

d. sweaty or pallor

e. Lightheadedness

References

1.Aggarwall, N., Selvendran, S., Vassiliou, V. (2016). Educational Case: A 57-old man

with chest pain. Oxford†Medical†Case†ReportsƆ©4®†, 62–65.

https://doi.org/10.1093/omcr/omw008

2. Quah, J. L. J., Yap, S., Cheah, S. O., Ng, Y. Y., Goh, E. S., Doctor, N., … Ong, M. E. H.

(2014). Knowledge of signs and symptoms of heart attack and stroke among singapore

residents. BioMed†Research†International†, 2014†, 572425.

https://doi-org.summit.csuci.edu/2014/572425

3. Wilkins, B., Hullikunte, S., Simmonds, M., Sasse, A., Larsen, P., Harding, S. A., …

Harding, S. A. (2019). Improving the prescribing gap for guideline recommended

medications post myocardial infarction. Heart¨†Lung†&†Circulation†, 28†(2), 257–262.

https://doi-org.summit.csuci.edu/10.1016/j.hlc.2017.10.025

4. Zafari, A Maziar, (2018). Myocardial infarction clinical presentation. MedscapeÆ

Retrieved via https://emedicine.medscape.com/article/155919-clinical