Case Study 6: Heart Disease

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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 CAD and 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 CXR showed cardiomegaly and a 12-lead ECG showed sinus tachycardia with left bundle branch block. You review his morning blood work and initial assessment.

Laboratory Testing:
Chemistry

H

Initial Assessment:

Complains of increased fatigue and SOB, especially with activity and “waking up and gasping for breath” at night, past two days.

Vital Signs: Temp 97.9 F BP 142/83 mmHg HR 105 bpm RR 18 bpm

1. As you review these results, which ones are of concern? Why?

Both Hematocrit and Hemoglobin are low; these results would indicate possible bleeding, which may lead to anemia. Anemia can lead to angina or aggravate Heart Failure symptoms. Low hemoglobin would also contribute to a decreased O2 saturation level because hemoglobin is responsible for carrying oxygen throughout the body. J.M also presents with an elevated blood pressure as well as Heart rate. The history indicated that HTN has been part of J.M’s past, CAD and HF are also noted, which contribute to the elevated BP. The decrease in Hematocrit and Hemoglobin will also contribute to the BP because the heart has to work harder to pump the blood to the body, and the blood is not carrying enough oxygen to deliver throughout the body. The respirations are a compensation of the elevated BP.
2. Knowing his history and seeing his condition this AM, what further questions are you going to ask J.M and his daughter?

What does your diet consist of? Weight?
Do you have any family history of

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