You are working in the internal medicine clinic of a large teaching hospital. Today your first ...

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?