IX.

DIAGNOSTIC TEST

Hematology Report

Test Results Unit References

Hemoglobin 14.40 g/dL 13.7-16.7
Hemotacrit 39.70 gm% 40.5-49.7
White Blood Cell 9.010 cell/mm3 5,000-10,000

DIFFERENTIAL COUNT

Segmenters 68 % 45-70
Lymphocyte 26 % 18-45
Monocyte 5 % 4-8
Eosinophil L 1 % 2-3
Platelet Count 182,000 Cell/mm3 150,000-450,000
Red Blood Cell L 4.68 X10^6/uL 4.7-6.1
MVC 84.80 fl 80-96
MCH 30.80 pg 27.0-31.0
MCHC H 36.30 g/dL 32.0-36.0
RDW 12.50 % 10.0-15.0

Table13. Hematology Report

Increased Mean Corpuscular Hemoglobin Concentration refers to the level of

MCHC above 36% or over to 36 grams/deceliter. High MCHC also known as
Hyperchromia or Macrocytic anemia. There is a high concentration of
hemoglobin in a red blood cells than the usual.

Decrease in eosinophil indicates that there are some conditions that is causing
the same. One condition would be drunkenness. Excessive alcohol intake or
excessive production or cortisol, like Cushing’s disease can result in a low
eosinophils count.

Clinical Chemistry

CONVENTIONAL UNIT SI UNIT

TEST RESULT REFERENCE UNIT RESULT REFERENCE UNIT
VALUE VALUE
Sodium 142 135-148 meq/L 142.00 135 - 148 mmol/L
Potassium 3.8 3.5-5.3 mmol/L 3.80 3.5-5.3 mmol/L
Total 155 140-239 mg/dl 4.01 3.62 - 6.18 mmol/L
Cholesterol
Triglyceride 129.1 35 - 160 mg/dl 1.46 0.40 - 1.81 mmol/L
s
HDL-C 35.5 29 – 71 mg/dl 0.92 0.75 - 1.84 mmol/L
LDL-C 93.7 66 – 178 mg/dl 2.43 1.71 - 4.61 mmol/L
VLDL-C 25.8 0 – 40 mg/dl 0.67 0 - 1.03 mmol/L
Cho/HDL 4.4 0.11
Ratio
Ionized Ca 1.12 1.12 – 1.32 mmol/L 1.19 1.12 – 1.32 mol/L
 Creatinine 1.24 0.62 – 1.28 mg/dL 109.62 58.81-113.15 umol/L
SGPT 32.0 10 – 40 IU/L 32.0 10 - 40 IU/L
HBA1C 5.9 4.3-6.4 % 5.90 0-0

Special Chemistry Section Test

HS TROPONIN-I
Reference Value:
RESULT: 2798.2 <19 ng/L

X-ray
HISTORY: Chest pain
Commparison: July 7, 2022

Clinical Information: PCAP

FINDINGS:
Linear densities in the lower left lung.
Heart is enlarged.
Atherosclerotic and tortuous aorta.
Diaphragm and sulci are intact.
Bony thorax are unremarkable

IMPRESSION:
Left lower lung fibrosis
Cardiomegaly
Atherosclerotic and tortuous aorta

X. MEDICAL AND SURGICAL MANAGEMENT

On November 9, 2022, Patient X was taken to Capitol University Medical Center

with chief complaint of chest pain and was diagnosed with Myocardial infarction.
On the day of admission, an X-ray and an ECG were performed.

The patient had a coronary angiogram on November 10, 2022, at 6:45 pm.
Following the procedure, surgical results revealed normal coronary arteries.

The following was given to the patient:

1. Generic name: Metropolol Tartrate

Brand name: Kapspargo Sprinkle, Lopressor, Toprol-XL
Classification: Cardioselective beta blockers
Dosage: 50mg Route: P.O.
Frequency: BID
Mechanism of Action:
- Metoprolol blocks β1 adrenergic receptors in heart muscle cells, thereby
decreasing the slope of phase 4 in the nodal action potential (reducing Na +
uptake) and prolonging repolarization of phase 3 (slowing down K + release).

Indication:
- indicated for the treatment of hypertension. They may be used alone or in
combination with other antihypertensive agents. Metoprolol tartrate tablets are
indicated in the long-term treatment of angina pectoris.

Contraindication:
- contraindicated in sinus bradycardia, heart block greater than first
degree, cardiogenic shock, and overt cardiac failure. It should be avoided in
asthmatics.

Adverse effects:
- Blurred vision
- chest pain or discomfort
- confusion
- dizziness, faintness, or lightheadedness when getting up suddenly from a lying
or - sitting position
- shortness of breath
- slow or irregular heartbeat
- sweating
- unusual tiredness or weakness

Nursing responsibilities/precautions:

- WARNING: Do not discontinue drug abruptly after long-term therapy

(hypersensitivity to catecholamines may have developed, causing exacerbation
of angina, MI, and ventricular arrhythmias).
-Taper drug gradually over 2 wk with monitoring.
-Ensure that patient swallows the ER tablets whole; do not cut, crush, or chew.
Toprol XL tablets may be divided at the score; divided tablets should be
swallowed whole, not crushed or chewed.
-Consult physician about withdrawing drug if patient is to undergo surgery
(controversial).
-Give oral drug with food to facilitate absorption.
-Provide continual cardiac monitoring for patients receiving IV metoprolol.

2. Generic name: sacubitril and valsartan

Brand name: Entresto
Classification: Angiotensin receptor blockers and neprilysin inhibitors.
Dosage: 50mg
Route: P.O.
Frequency: BID
Mechanism of Action:
- It works by blocking the action of neprilysin, thus preventing the breakdown of
natriuretic peptides, which leads to a prolonged duration of the favorable effects
of these peptides.
Indication:
To reduce the risk of cardiovascular death and hospitalization for heart failure in
patients with chronic heart failure (NYHA Class ll-IV) and reduced ejection
fraction.

Contraindication:
Contraindications Hypersensitivity to sacubitril, valsartan, or any component of
the formulation; history of angioedema related to previous ACE inhibitor or ARB
therapy; concomitant use or use within 36 hours of ACE inhibitors; concomitant
use of aliskiren in patients with diabetes

Adverse Effects:
- Anaemia
- asthenia
- cough
- diarrhoea
-dizziness
- electrolyte imbalance
- gastritis
- headache
-hypoglycaemia
-hypotension
- nausea
- renal impairment
- syncope
- vertigo

Nursing Responsibilities/ Precautions:

People with the following conditions should use valsartan with extreme
caution:

- Impaired kidney function due to an increased risk of hyperkalemia and

acute kidney failure
- Hypotension (low blood pressure), due to a potentially life-threatening
drop in blood pressure
- Liver disease, due to an increased risk of hepatitis (liver inflammation)
 If treatment is started, blood pressure, kidney function, and liver enzymes
must be carefully monitored to avoid complications.

3. Generic Name:
Omeprazole
Brand Name:
Omepron
Classification:
Proton Pump Inhibitor
Dosage:
1 Cap
Dosage: 40mg
Route: P.O.
Frequency: OD

Mechanism of Action:
- Reduces GastricAcid Secretion andincreases Gastricmucus and bicarbonate
production, creating protective coating ongastric mucosa andeasing
discomfortfrom excess gastricacid
.
Indication:
Omeprazole may be sold under the brand names Prilosec or Prilosec OTC. It
may also be in combination medications including Zegerid or Zegirid OTC. This
medication is used to treat gastroesophical reflux disease, erosive esophagus, or
gastric and duodenal ulcers.

Contraindication:
- Omeprazole intake can increase the risk for exacerbation of symptoms of lupus
erythematosus in individuals with history of the same.
-Patients can present with diffuse skin rashes. ...
- In individuals with history of lupus, omeprazole use is either discouraged or is
administered very carefully with periodical follow-up for any activation of lupus
symptoms.

Adverse Effects:
- Headaches
- Feeling sick (nausea)
- Being sick (vomiting) or diarrhoea
- Stomach pain
- Constipation
- Farting (flatulence)
Nursing Responsibilities/ Precautions:
- Assess Vital Signs
- Check for abdominal Pain, emesis,Diarrhea or constipation.
- Evaluate fluid and intake
- Watch for elevated liver function testresults
- Tell patient to take 30-60 minutes before a meal, preferably in morning.
- Instruct patient to swallow capsulesor tablets whole and no to chew
orcrash them.
- Caution patient to avoid driving andother hazardous activities until
heknow drug effects concentration andalertness

4. Generic Name: enoxaparin

Brand Name: Lovenox, Lovenox HP, Clexane, Clexane Forte
Classification:
Heparins
Dosage:
0.6 cc
Dosage: 0.6 cc
Route: SQ
Frequency: Q12 hours
Mechanism of Action:
- The mechanism of action of enoxaparin is antithrombin-dependent. It acts
mainly by accelerating the rate of the neutralization of certain activated
coagulation factors by antithrombin, but other mechanisms may also be involved.
The antithrombotic effect of enoxaparin is well correlated to the inhibition of factor

Indication:
Enoxaparin Sodium Injection is indicated for the prophylaxis of deep vein
thrombosis (DVT), which may lead to pulmonary embolism (PE):

- in patients undergoing abdominal surgery who are at risk for thromboembolic

complications [see Clinical Studies ( 14.1 )]
in patients undergoing hip replacement surgery, during and following
hospitalization
- in patients undergoing knee replacement surgery
- in medical patients who are at risk for thromboembolic complications due to
severely restricted mobility during acute illness

Contraindication:
Enoxaparin sodium is contraindicated in patients with:
- Active major bleeding
- History of immune-mediated heparin-induced thrombocytopenia (HIT) within the
past 100 days or in the presence of circulating antibodies
- Known hypersensitivity to enoxaparin sodium (e.g., pruritus, urticaria,
anaphylactic/anaphylactoid reactions
- Known hypersensitivity to heparin or pork products Omeprazole intake can
increase the risk for exacerbation of symptoms of lupus erythematosus in
individuals with history of the same.

Adverse Effects:
- Nausea
- diarrhea
- anemia
- confusion
- pain, bruising, redness, or irritation where the medicine was injected.

Nursing Responsibilities/ Precautions:

- Monitor for signs of bleeding
- Administer in subcutaneous tissue
- DO NOT eject air bubble prior to injection
- DO NOT aspirate or massage site

5. Generic Name: Aspirin

Brand Name: Arthrinol, Arthrisin,Aspergum Bayer Aspirin, Coryphen,Easpirin,
Ecotrin,Empirin, Entrophen
Classification:
Nonnarcoticanalgesic,nonsteroidal anti-inflammatory,antipyretic,antiplatele
Dosage:
80 mg
Route: P.O.
Frequency: OD

Mechanism of Action:
Blocks pain impulses in CNS, inhibition of prostaglandin synthesis, antipyretic
action results from vasodilation of peripheral vessels, decreases platelet
aggregation

Indication:
Mild to moderate pain or fever including rheumatoid arthritis, osteoarthritis,
thromboembolic disorders, transientischemicattacks ,rheumatic fever,
postmyocardial infarction, prophylaxis of MI, ischemic stroke.

Contraindication:
Hypersensitivity to salicylates tatrazin, GI bleeding, bleeding disorders, chidren
<12yr, children with flu like symptoms, lactation, vit K deficiency, peptic ulcer.

Adverse Effects:
Aspirin works similarly to other NSAIDs but also suppresses the normal
functioning of platelets. One common adverse effect is an upset stomach. More
significant side effects include stomach ulcers, stomach bleeding, and worsening
asthma.

Nursing Responsibilities/ Precautions:

- Monitor for loss of tolerance to aspirin. The reaction is nonimmunologic;
symptoms usually occur 15 min to 3 h after ingestion: profuse rhinorrhea,
erythema, nausea, vomiting, intestinal cramps, diarrhea.
- Lab tests: frequent PT and IRN with concurrent anticoagulant therapy; more
frequent fasting blood glucose levels with diabetes.
- Monitor the diabetic child carefully for need to adjust insulin dose. Children on
high doses of aspirin are particularly prone to hypoglycemia (see Appendix F).
- Monitor for salicylate toxicity. In adults, a sensation of fullness in the ears,
tinnitus, and decreased or muffled hearing are the most frequent symptoms
associated with chronic salicylate overdosage.
- Monitor children closely because salicylate toxicity is enhanced by the
dehydration that frequently accompanies fever or illness. Children tend to
manifest salicylate toxicity by hyperventilation, agitation, mental confusion, or
other behavioral changes, drowsiness, lethargy, sweating, and constipation.
- Note: Potential for toxicity is high in older adults and patients with asthma, nasal
polyps, perennial vasomotor rhinitis, hay fever, or chronic urticaria

6. Generic Name: Clopigrel

Brand Name: Plavix
Classification:
Platelet aggregation inhibitors.
Dosage:
75 mg
Route: P.O.
Frequency: OD
Mechanism of Action:
- Inhibits platelet aggregation by irreversibly inhibiting the binding of ATP to
platelet receptors

Indication:
Reduction of atherosclerotic events (MI, stroke, vascular death) in patients at risk
for such events including recent MI,acute coronary syndrome (unstable
angina/non-Q-wave MI), stroke, or peripheral vascular disease.

Contraindication:
- Hypersensitivity
- Pathologic bleeding( peptic ulcer, intracranialhemorrhage)
- Lactation.
- Use Cautiously in:
Patients at risk for bleeding (trauma, surgery, or other pathologic conditions)
History of GIbleeding/ulcer disease Severe hepatici mpairment.
.

Adverse Effects:
CNS: Depression, Dizziness, Fatigue, Headache.
EENT: Epistaxis.
Resp: Cough, Dyspnea.
CV: Chest Pain, Edema,Hypertension.
GI: GI Bleeding, Abdominal Pain, Diarrhea,Dyspepsia, Gastritis.
Derm: Pruritus, Purpura,Rash.
Hemat: Bleeding, Neutropenia, Thrombotic Thrombocytopenic Purpura.
Metab: Hypercholesterolemia.
MS: Arthralgia, Back Pain.
Misc:Fever, Hypersensitivity Reactions.

Nursing Responsibilities/ Precautions:

Assessment:
Assess patient for symptoms of stroke,peripheral vascular disease, or MI
periodically during therapy. Monitor patient for signs of thrombotic thrombocytic
purpura (thrombocytopenia, microangiopathic hemolytic anemia, neurologic
findings, renal dysfunction, fever). May rarely occur, even after short exposure
(<2 wk). Requires prompt treatment.
Implementation:
Discontinue clopidogrel 5-7 days before planned surgical procedures.
PO:
Administer once daily without regard to food.
Patient/Family Teaching
 Instruct patient to take medication exactly as directed. Take missed doses as
soon as possible unless almost time for next dose; do not double doses. Advise
patient to notify health care professional promptly if fever, chills, sore throat, or
unusual bleeding or bruising occurs. Advise patient to notify health care
professional of medication regimen prior to treatment or surgery.

7. Generic Name: Temozolomide Temozolomide (TMZ)

Brand Name: Temodar
Classification:
Vasodilator
Dosage:
35mg
Route: P.O.
Frequency: BID

Mechanism of Action:
Mechanism of Action Temozolomide is a drug which is rapidly and
nonenzymatically converted to the active alkylating metabolite MTIC [ (methyl-
triazene-1-yl)-imidazole-4-carboxamide]; this conversion is spontaneous,
nonenzymatic, and occurs under physiologic conditions in all tissues to which it
distributes

Indication:
Temozolomide Capsules are indicated for the treatment of adult patients with
refractory anaplastic astrocytoma who have experienced disease progression on
a drug regimen containing nitrosourea and procarbazine.

Contraindication:
Temozolomide is contraindicated in patients with a history of hypersensitivity
reactions to:

- Temozolomide or any other ingredients in Temozolomide capsules

- dacarbazine, since both Temozolomide and dacarbazine are metabolized to the
same active metabolite 5- (3-methyltriazen-1-yl)-imidazole-4-carboxamide

Adverse Effects:
- seizure (convulsions);
- sudden chest pain or discomfort, wheezing, dry cough;
- low blood cell counts--fever, chills, mouth sores, skin sores, easy bruising,
unusual bleeding, pale skin, cold hands and feet, feeling light-headed or short of
breath; or
- liver problems--nausea, upper stomach pain, itching, tiredness, loss of appetite,
dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes).

Nursing Responsibilities/ Precautions:

For that regimen, there are no special precautions. Universal precautions will be
the most effective. Do make sure the patient is given anti-nausea meds 1 hour
prior to Temodar and XRT. Both are highly emetogenic and will cause the patient
to be very sick.

8. Generic Name: Carvedilol

Brand Name: Coreg, Coreg CR
Classification:
Non-cardioselective beta blockers
Dosage:
25mg
Route: P.O.
Frequency: BID

Mechanism of Action:
Carvedilol is a potent antihypertensive agent with a dual mechanism of action. At
relatively low concentrations it is a competitive beta-adrenoceptor antagonist and
a vasodilator, whereas at higher concentrations it is also a calcium channel
antagonist.

Indication:
Carvedilol is a non-selective adrenergic blocker indicated for the chronic therapy
of heart failure with reduced ejection fraction (HFrEF), hypertension, and left
ventricular dysfunction following myocardial infarction (MI) in clinically stable
patients.

Contraindication:
Carvedilol is contraindicated in the following conditions: Bronchial asthma or
related bronchospastic conditions. Deaths from status asthmaticus have been
reported following single doses of Carvedilol. Second- or third-degree AV block.
Sick sinus syndrome. Severe bradycardia (unless a permanent pacemaker is in
place).

Adverse Effects:
- Dizziness
-Edema (fluid accumulation)
- Decreased heart rate
-Low blood pressure
- Weight gain
- increased blood glucose levels (hyperglycemia)
- Diarrhea

Nursing Responsibilities/ Precautions:

- WARNING: Do not discontinue drug abruptly after chronic therapy

(hypersensitivity to catecholamines may have developed, causing exacerbation
of angina, MI, and ventricular arrhythmias); taper drug gradually over 2 wk with
monitoring.
- Consult with physician about withdrawing drug if patient is to undergo surgery
(withdrawal is controversial)

9. Generic Name: Ramipril

Brand Name: Altace
Classification:
Angiotensin Converting Enzyme Inhibitors
Dosage:
10mg
Route: P.O.
Frequency: OD

Mechanism of Action:
Mechanism of Action Ramipril is an ACE inhibitor which prevents the formation of
angiotensin II from angiotensin I and exhibits pharmacologic effects that are
similar to captopril. Ramipril must undergo enzymatic saponification by esterases
in the liver to its biologically active metabolite, ramiprilat.

Indication:
This medication is an angiotensin-converting enzyme (ACE) inhibitor, used alone
or in combination with other medications to treat high blood pressure. It is also
used to reduce the risk of heart attack and stroke in patients at risk for these
problems and to improve survival in patients with heart failure after a heart
attack.

Contraindication:
Contraindications to its use include volume-depleted patients, a history of
angioedema while on an ACE inhibitor, pregnancy and hypotension. [citation
needed] People should not take ramipril (or any ACE inhibitors) if they have
hyperkalemia.Sick sinus syndrome. Severe bradycardia (unless a permanent
pacemaker is in place).

Adverse Effects:
- hives; severe stomach pain; difficult breathing; swelling of your face, lips,
tongue, or throat. Call your doctor at once if you have: a light-headed feeling, like
you might pass out; jaundice (yellowing of your skin or eyes)

Nursing Responsibilities/ Precautions:

check the following to tell if this drug is working, and to check for side effects:
- blood pressure
- kidney function
- liver problems
- electrolyte changes
- blood counts
- Surgical management

SURGICAL MANAGEMENT

A coronary angiogram is a procedure that uses X-ray imaging to see your heart's
blood vessels. The test is generally done to see if there's a restriction in blood
flow going to the heart.

Coronary angiograms are part of a general group of

procedures known as heart (cardiac)
catheterizations. Cardiac catheterization procedures
can both diagnose and treat heart and blood vessel
conditions. A coronary angiogram, which can help
diagnose heart conditions, is the most common type
of cardiac catheterization procedure.

During a coronary angiogram, a type of dye that's

visible by an X-ray machine is injected into the blood
vessels of your heart. The X-ray machine rapidly
takes a series of images (angiograms), offering a
look at your blood vessels. If necessary, your doctor
can open clogged heart arteries (angioplasty) during
your coronary angiogram

During the you lie on your back on an X-ray table. Because the table may be
tilted during the procedure, safety straps may be fastened across your chest and
legs. X-ray cameras will move over and around your head and chest to take
pictures from many angles.

An IV line is inserted into a vein in your arm. You may be given a sedative
through the IV to help you relax, as well as other medications and fluids. You'll be
very sleepy and may drift off to sleep during the procedure, but you'll still be able
to be easily awakened to follow any instructions.

Electrodes on your chest monitor your heart throughout the procedure. A blood
pressure cuff tracks your blood pressure and another device, a pulse oximeter,
measures the amount of oxygen in your blood.
A small amount of hair may be shaved from your groin or arm where a flexible
tube (catheter) will be inserted. The area is washed and disinfected and then
numbed with an injection of local anesthetic.

A small incision is made at the entry site, and a short plastic tube (sheath) is
inserted into your artery. The catheter is inserted through the sheath into your
blood vessel and carefully threaded to your heart or coronary arteries.

Threading the catheter shouldn't cause pain, and you shouldn't feel it moving
through your body. Tell your health care team if you have any discomfort.

Dye (contrast material) is injected through the catheter. When this happens, you
may have a brief sensation of flushing or warmth. But again, tell your health care
team if you feel pain or discomfort.

The dye is easy to see on X-ray images. As it moves through your blood vessels,
your doctor can observe its flow and identify any blockages or constricted areas.
Depending on what your doctor discovers during your angiogram, you may have
additional catheter procedures at the same time, such as a balloon angioplasty or
a stent placement to open up a narrowed artery. Other noninvasive tests, such
as ultrasound, may help your doctor evaluate identified blockages.

Having an angiogram takes about one hour, although it may be longer, especially
if combined with other cardiac catheterization procedures. Preparation and post-
procedure care can add more time