PHINMA EDUCATION - CAGAYAN DE ORO COLLEGE

MAX SUNIEL ST., CARMEN, CAGAYAN DE ORO CITY

LEVEL III - 1ST SEMESTER
S.Y. 2023-2024
CARE OF OLDER ADULT RLE
NUR 152 PERIODICAL 3 WEEK 1
CASE SCENARIO - 1

Clinical Instructor : Elmo Uzon

Section :NUR 152- BSN3-02

Members:
Antipunan, Michelle
Bayana, Chaz
Bersabal, Angely Mae
Cababaros, Alliah
Glorial, Ferly
Hadji Ali, Janisa
Ibrahim, Nor-em
Jaraula, Althea
Magbanua, Nice
Mandin, Mary
Pogoy, Jade
Salud, Aubrey Faye

1. A 53-year-old man, hypertensive, presents at the emergency room complaining of

heavy substernal chest pain during exertion, lasting for 5 minutes and relieved by rest.

A. What is the most likely diagnosis?

- Based on the scenario given, the 53 year old man is hypertensive, complained of heavy
substernal chest pain during exertion, lasting for 5 minutes and relieved at rest, the
patient most likely to have a diagnosis of chronic stable angina pectoris.

B. What is the underlying pathophysiology?

- Pathophysiology – CAD - Stable Angina
- The term “ischemic heart disease” implies a physiologically significant myocardial
oxygen supply/demand mismatch. The most common cause of this mismatch is flow-
limiting atherosclerotic narrowing of the coronary artery, resulting in the potential for
inadequate coronary flow. Reduced oxygen carrying capacity, eg, anemia, carbon
 monoxide poisoning or increased oxygen demand due to tachyarrhythmias, hypertensive
emergencies or severe aortic valve stenosis may also precipitate angina.

C. What is the first and initial approach to chest pain?

- The ABCs, which stand for airway, breathing, and circulation, are the first things you
should evaluate when a patient complains of chest pain. Next comes a focused history
and physical examination, as well as an electrocardiogram, or ECG. That ECG needs to
be done right away, and it needs to be interpreted. To assess the patient for any
potentially fatal conditions.

D. What is the best initial diagnostic test?

- Initial diagnostic tests will be electrocardiogram, a chest X-ray, blood tests, an MRI is
used to check for damage to your heart or aorta.

E. What is the next best step if the initial ECG and chest x-ray are normal?
- . A person with a heart condition receives normal results from an X-ray and an ECG
however still having substantial substernal chest pain. The doctor may advise further
tests in this situation, such as a physical exam (Listen to heart sounds), but arrange CT
pulmonary angiography (CTPA) is the best next step or recommended course of action.

F. What is the first line of treatment to reduce angina?

- In inhibiting how quickly the heart responds to exercise, beta blockers are used as first-
line medication to treat angina and enhance exercise tolerance. Despite the fact that it
minimizes the likelihood for cardiovascular mortality and myocardial infarction (MI) by
30% in post-infarction patients, their advantages in people having persistent coronary
artery disease remain unclear. The beta1-selective medications that include metoprolol
and atenolol are the most commonly utilized in angina within the setting of regular left
ventricular function.
2. A 52-year old male, smoker and hypertensive, presents with severe substernal chest
pain,radiating to the right arm, with associated diaphoresis. The chest pain persists
despite taking sublingual nitrates. On physical examination, his blood pressure is 130/80
and heart rate is 90 bpm.

A. What is the most likely diagnosis?

- The patient's symptoms suggest unstable angina due to hypertension and smoking. The
chest pain that radiates to the extremities, discomfort, and shortness of breath, are
indicative of an obstruction. These symptoms are not easily relieved with medication.

B. What is the best initial diagnostic test?

- Your doctor might order tests to assist identify or check out heart-related issues as the
cause of your chest pain. These could include: Immediate tests An electrocardiogram
(ECG or EKG) is one of the initial tests a doctor may order to determine the cause of
chest pain. A chest X-ray, blood tests, an MRI is used to check for damage to your heart
or aorta and an echocardiogram.

C. What diagnostic test is used to distinguish unstable angina and NSTEMI?

- The primary diagnostic test used to distinguish unstable angina and non-ST segment
elevation myocardial infarction (NSTEMI) is a blood test to measure cardiac biomarkers,
such as troponin levels.
In unstable angina, troponin levels typically remain within the normal range because
there is no permanent damage to the heart muscle. However, in NSTEMI, there is some
degree of heart muscle damage, which releases troponin into the bloodstream, causing
an elevation in troponin levels.
Other diagnostic tests, such as an electrocardiogram (ECG) and clinical assessment of
symptoms, are also important in making the distinction. An ECG may show changes in
the ST segment in NSTEMI, whereas it often appears normal or with transient changes
in unstable angina. Ultimately, a combination of clinical evaluation, troponin levels, and
ECG findings is typically used to differentiate between these two cardiac conditions
.
D. What is the most common underlying pathophysiology?
- Angina is usually caused by atherosclerosis disease and most often is associated with a
significant obstruction of at least one major coronary artery. Normally, the myocardium
extracts a large amount of oxygen from the coronary circulation to meet its continuous
demands. When demand increases, flow through the coronary arteries needs to be
increased. When there is blockage in a coronary artery, flow cannot be increased and
ischemia results. In unstable angina, there is reduced blood flow in a coronary artery,
often due to rupture of an atherosclerotic plaque. A clot begins to form on top of the
coronary lesion, but the artery is not completely occluded. This is an acute situation that
can result in chest pain and other symptoms that may be referred to as preinfarction
angina because the patient will likely have an MI if prompt intervention does not occur.