CASE STUDY 1: ACUTE ANTEROLATERAL MYOCARDIAL INFARCTION

Present Illness
Patient A is white, 60 years of age, and works as a cab driver. While driving home after work, he develops an aching in his chest
and slight, regular palpitations. The ache is still present when he goes to bed, when he wakes several times during the night,
and when he gets up in the morning, seven hours after retiring. He drinks some soda water, but when the aching does not
improve, he decides to go to the emergency department.
At the hospital, Patient A complains of chest pain accompanied by diaphoresis, slight shortness of breath, and nausea. Relief of
pain is obtained with IV morphine sulfate. When the patient is admitted to the critical care unit (CCU), his symptoms are
generally unremarkable except for recurrent pain.
Medical History
Patient A experienced the usual childhood illnesses without rheumatic fever. As an adult, he has a history of hypertension
(documented on discharge from the Army at 45 years of age and when hospitalized two years ago) that has not been treated.
Past surgery includes tonsillectomy and adenoidectomy as a child. A cataract was removed from his right eye two years ago.
Patient A's father died of an MI at 55 years of age. His mother is alive and well, although the patient does not know her age.
Two brothers, 65 and 58 years of age, are alive and well. The patient lives alone and works approximately 72 hours per week.
He has been married and divorced twice; the last divorce was four years ago. He has no children.
Assessment and Diagnosis
Upon admittance to the CCU, a full physical exam is conducted (Table 4). An ECG is done and shows ST elevation. Several
laboratory tests are ordered, with the following results:
 Serum cardiac enzymes:
o CK: 164 IU/L
o LDH: 219 IU/L
 Serum glutamic-oxaloacetic transaminase (SGOT): 31 IU/L
 CBC: Within normal limits
 Electrolytes: Within normal limits
 Urinalysis: Within normal limits

PATIENT A'S PHYSICAL EXAM RESULTS

Parameter Findings
General appearance White male in mild distress, appears his stated age
Height: 5 feet 9 inches (176 cm)
Weight: 195 pounds (88.5 kg)

Head and eyes Normocephalic

Left pupil briskly reactive to light
Phacotomy scar on right pupil
Optic fundi show sharp disks with narrow arteries, no hemorrhages or exudates

Ears Tympanic membranes intact

Neck Supple, without masses or thyromegaly
Jugular venous pulse not visualized

Chest Clear to auscultation and percussion

Abdomen Without masses, tenderness, or splenomegaly
Liver palpated at rib border
Bowel sounds normal

Extremities Peripheral pulses full, equal, and without bruits

 Parameter Findings
Genitourinary Within normal limits
system
Neurologic status Oriented to person, place, and time
Cranial nerves II–XII grossly intact
Deep tendon reflexes 2+ with symmetrical flexor plantar responses
Motor and sensory grossly normal

Cardiovascular Point of maximal impulse sixth intercostal space in the midclavicular line of normal intensity and
system duration, without heaves or thrills
Vital Signs
Blood pressure 140/95 mm Hg
Temperature 98.6° F
Heart rate 55 bpm
Respiratory rate 18 breaths per minute
Table 4
Source: Author
Based on the results of the assessment, Patient A is diagnosed with:
 Acute anterolateral MI, generally uncomplicated
 Atherosclerotic cardiovascular disease
 Hypertension: Untreated for 15 years, probably essential hypertension given age at onset
Management
Patient A's vital signs are stable for the remainder of the day, with a sinus bradycardia of 56 bpm. Early in the morning the next
day, the patient awakes with nausea and diaphoresis. His blood pressure has decreased to 90/60 mm Hg with sinus bradycardia
of 40 bpm. PVCs are present. The patient is treated with 0.5 mg IV atropine sulfate twice, after which his heart rate increases to
70 bpm and his blood pressure increases to 130/68 mm Hg. Unifocal PVCs are then treated with 150 mg of amiodarone IV over
10 minutes followed by an amiodarone drip at 1 mg/minute for 6 hours, then 0.5 mg/minute for 12 hours.
Later in the day, Patient A's vital signs are:
 Blood pressure: 130/90 mm Hg
 Temperature: 98.4° F
 Heart rate: 60 bpm
 Respiratory rate: 18 breaths per minute
The patient has no further chest pain, but he reports that his nausea persists after meals.
Two days later, Patient A's LDH value rises to 310 IU/L; other enzyme levels remain essentially the same as the admission
values. ECG shows ST elevation diminishing from previous levels. The amiodarone is discontinued without return of the PVCs.
His vital signs remain stable, no further arrhythmias are noted, and his nausea is resolved. On day three, Patient A is moved out
of the CCU and started on cardiac rehabilitation.
On day four, a treadmill test is done at 50% effort with negative results. Patient A is discharged on day seven. The medical plan
is to continue treatment of his hypertension with propranolol. The patient plans to return to driving his cab, but for fewer hours
per week.
Study Questions
1. List Patient A's major risk factors for CHD and discuss other possible risk factors for heart disease.
2. Discuss the pathophysiology of CHD and the signs and symptoms (i.e., classic physical exam findings) exhibited by the
acutely ill patient during an MI. What are the common complications post-infarction?
3. What patient history points indicate the diagnosis of MI in Patient A's case?
4. Correlate the pathology, complications, and nursing care for a patient with MI with the patent's progress from the
CCU to home.
5. Review the action, side effects, and specific nursing care for the drugs commonly used in the treatment of patients
with MI, including:
o Analgesics (e.g., morphine)
 o Sedatives (e.g., phenobarbital)
o Antianxiety medications (e.g., diazepam)
o Anticoagulants (e.g., heparin)
o Laxatives/stool softeners
o Vasopressors (e.g., norepinephrine)
o Vasodilators (e.g., nitroglycerin)
o Diuretics (e.g., furosemide)
o Cardiotonics (e.g., digoxin)
6.
o Cardiac stimulants (e.g., epinephrine, isoproterenol)
o Cardiac depressants (e.g., amiodarone)
o Antilipidemic drugs (e.g., atorvastatin)
7. Describe the treatment for MI.
8. What diagnostic tests usually confirm an MI?
9. Nursing care of the patient with MI is directed toward detecting complications, preventing further myocardial
damage, and promoting comfort, rest, and emotional well-being. Discuss the specific care needs for each situation
listed below:
o On admission to the CCU
o During episodes of chest pain
o Fluid retention
o Rest
o Elimination
o Exercise and immobility
o Psychologic stress
o Patient teaching and discharge panning for a cardiac rehabilitation program
10. Psychologic support is imperative for the well-being of the patient with MI. Discuss the patient's potential anxieties
and fears and the best means to provide realistic emotional support and reassurance.
11. Should Patient A make specific lifestyle changes? If so, what changes and how can these be encouraged?
12. Define silent MI. How common is it?
PATIENT A'S PHYSICAL EXAM RESULTS

Parameter Findings
General appearance White male in mild distress, appears his stated age
Height: 5 feet 9 inches (176 cm)
Weight: 195 pounds (88.5 kg)

Head and eyes Normocephalic

Left pupil briskly reactive to light
Phacotomy scar on right pupil
Optic fundi show sharp disks with narrow arteries, no hemorrhages or exudates

Ears Tympanic membranes intact

Neck Supple, without masses or thyromegaly
Jugular venous pulse not visualized

Chest Clear to auscultation and percussion

Abdomen Without masses, tenderness, or splenomegaly
Liver palpated at rib border
Bowel sounds normal
 Parameter Findings
Extremities Peripheral pulses full, equal, and without bruits
Genitourinary Within normal limits
system
Neurologic status Oriented to person, place, and time
Cranial nerves II–XII grossly intact
Deep tendon reflexes 2+ with symmetrical flexor plantar responses
Motor and sensory grossly normal

Cardiovascular Point of maximal impulse sixth intercostal space in the midclavicular line of normal intensity and
system duration, without heaves or thrills
Vital Signs
Blood pressure 140/95 mm Hg
Temperature 98.6° F
Heart rate 55 bpm
Respiratory rate 18 breaths per minute
Table 4
Source: Author
IVF: PLR 1L @ 60CC/H, Remaining Solution of 200 cc

To ff: PNSS 1L @60 CC/H