Title: You are working in the internal medicine clinic of a large teaching hospital. Today your first ... Post by: dancan77 on Feb 28, 2018 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. Laboratory Results Chemistry Sodium 142 mEq/L Chloride 95 mEq/L Potassium 3.9 mEq/L Creatinine 0.8 mg/dL Glucose 82 mg/dL BUN 19 mg/dL Complete Blood Count WBC 5400/mm3 Hgb 11.5 g/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) 142/83 mm Hg Heart rate 105 beats//min Respiratory rate 18 breaths/min As you review these results, which ones are of possible concern, and why? Question 2 After taking the second NTG SL tablet, B.T. complains of a terrible headache and worries that he is getting worse. What is happening, and what should you tell him? Question 3 Five minutes after the first NTG tablet, B.T. states that the discomfort is still there and only slightly relieved. Explain what you can expect to be doing while waiting for emergency medical system (EMS) personnel to arrive. Also what other actions will you take at this time? Question 4 B.T. is still uncomfortable, and he has an unopened bottle of sublingual nitroglycerin (SLNTG) tablets. His blood pressure is 158/98, and his pulse is 122. You decide to give him one tablet. After 5 minutes, which is the appropriate action to take? a. If the chest discomfort is relieved, call 911. b. If the chest discomfort is not relieved, give another SL NTG tablet, and wait 5 minutes more. c. If the chest discomfort is not relieved, have someone else call 911 while you give B.T. another SL NTG tablet. d. If the chest discomfort is not relieved, obtain a 12-lead electrocardiogram (ECG) to look for ischemic changes, and call 911. Question 5 Six weeks after you start working with B.T., he admits that he has been under a lot of stress. He is walking on the treadmill and rubs his chest and says, It feels really heavy on my chest right now. You feel his pulse and note that his skin is slightly diaphoretic and that he is agitated and appears to be anxious. What is the first action you are going to do? What other information will you obtain? Explain. Question 6 B.T.'s wife takes you aside and tells you, I'm so worried for B. I grew up in a really dysfunctional family where there was a lot of violence. B. has been so good to the kids and me. I'm so worried I'll lose him that I have nightmares about his heart stopping. I find myself suddenly waking up at night just to see if he's breathing. How are you going to respond? Title: You are working in the internal medicine clinic of a large teaching hospital. Today your first ... Post by: B Briggs on Feb 28, 2018 J.M.'s CAD, HTN, or possibly heart failure (HF). More testing is needed to verify. His Hgb and Hct are slightly decreased, and further testing is needed to determine whether an iron deficiency or vitamin B12 deficiency exists. that this is a side effect of the NTG and that he is not getting worse. Encourage him to rest quietly as the NTG may also cause a drop in blood pressure (orthostatic changes) if he tries to get up. B.T. is transported to the emergency department of a local hospital and undergoes another cardiac catheterization with coronary stent placement. (ED) while you stay with B.T. Have B.T. chew two low-dose (81 mg, or baby) aspirin tablets, if available. Following the department protocols, while you are waiting for the medics, start 2 to 4 L of O2/NC and establish intravenous (IV) access, in case IV medications have to be administered. Run a 12-lead ECG or rhythm strip to look for dysrhythmias and ischemic changes. Run a long rhythm strip. If B.T. needs to be transported by the paramedics to the ED, it may be valuable to the medical personnel at the hospital. Continue to observe B.T. carefully and monitor his vital signs, reassure him, and make him as comfortable as possible. Notify B.T.'s attending physician and his wife. Continue to monitor his vital signs, and consider checking a 12-lead ECG (if available) to look for ischemic changes. Keep him quiet, and reassure him that you will stay with him. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after one dose of SL NTG, call 911 immediately. The patient can take one more tablet while awaiting emergency care, and a third tablet 5 minutes later, but no more than three tablets total. These guidelines reflect the fact that angina pain that does not respond to NTG might indicate that an MI is occurring. heart and decrease his body's need for oxygen. You will also check his vital signs and ask whether he has any SL NTG tablets with him. Suggest that she practice stress-relaxation techniques with him. Ask whether she would like to talk to someone about her anxiety. |