ANGINA CASE STUDY

Scenario

R.K. is an 85-year-old woman who lives with her husband, who is 87. Two nights before her

admission to your cardiac unit, she awoke with heavy substernal pressure accompanied by

epigastric distress. The pain was reduced somewhat when she rolled onto her side but did not

completely subside for about 6 hours. The next night, she experienced the same chest pressure.

The following morning, R.K.’s husband took her to the physician, and she was subsequently

hospitalized to rule out myocardial infarction (MI). Lab specimens were drawn in the emergency

department. She was given 325 mg chewable, non–enteric-coated aspirin, and an IV line was

started. She was placed on oxygen (O2) at 2 L via nasal cannula.

You obtain the following information from your history and physical examination: R.K. has no history

of smoking or alcohol use, and she has been in good general health, with the exception of

osteoarthritis of her hands and knees and some osteoarthritis of the spine. Her only medications are

simvastatin (Zocor), ibuprofen as needed for bone and joint pain, and “herbs.” Her admission vital

signs (VS) are blood pressure 132/84, pulse 88, respirations 18 breaths/min, and oral temperature

99 ° F (37.2 ° C). Her weight is 114 pounds (51.7 kg) and height is 5 ft, 4 in. (163 cm). Moderate

edema of both ankles is present; capillary refill is brisk, and peripheral pulses are 1+. You hear a soft

systolic murmur. She denies any discomfort at present. You place her on telemetry, which shows the

rhythm in the following figure.

1. Identify her cardiac rhythm: #171 ATI Premature Atrial Contractions -Sinus Rhythm with

PACS

(Modified from Huszar R. Basic Dysrhythmias: Interpretation and Management—Revised Reprint.

ed. 3, St. Louis, MO: Mosby; 2007.)

2. Give at least 2 reasons for inserting an IV line: Page #676 MedSurg, explains that an IV Line is

used in order to give fluids and to give medications/thrombolytics.

3. Explain the purpose of the aspirin tablet. Why is “non–enteric-coated” aspirin specified? What

would be a contraindication to administering aspirin? Aspirin is effective in reducing the blood

clots that are blocking a coronary artery during an acute MI. In the case of non-enteric coated

aspirin tablets they dissolve faster. ATI Page #194 explains that the contraindications to

administering aspirin are: Allergies, Bleeding Disorders, Ulcers, and Hemorrhagic Stroke.

4. What additional history and physical information should you obtain related to her admitting

diagnosis? Name at least 4 for each.

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ANGINA CASE STUDY

Page #192 ATI

 History

 Family History of Cardiac Disorders?

 Stress?

 Any Allergies?

 Race?

 Physical

 Has this happened in the past 2 days?

 What medications or herbs are being taken?

 What does your diet consist of?

 Do you smoke?

5. List 7 laboratory or diagnostic tests you would expect to be performed; suggest what each might

contribute. Page# 192 ATI

1. 12 lead ECG- cardiac monitoring

2. D-DIMER- clotting

3. O2 STAT- oxygen circulation

4. CK-MB- chest pain

5. Cardiac Troponin T & I – cardiac damage

6. Myoglobin- infarcted myocardium

7. C- Reactive Protein -ischemic

6. What other sources, in addition to cardiac ischemia, might be responsible for her chest and

abdominal discomfort?

ATI P.191 When blood flow to the heart is compromised, ischemia causes chest pain. The two

risk factors that fit within R.K.’s category includes metabolic disorders, and postmenopausal

age. The prescribed medication Zocor (simvastatin) is a statin used to lower cholesterol, and

a risk factor for Angina is also Hyperlipidemia. Along with that this medication can cause

indigestion and heartburn, another cause for concern is the use of “herbs” that can both

react with medication and cause an adverse effect related to ingredients and age. Textbook

Page 759: relates gender to CAD. The text states that women typically have smaller coronary

arteries and frequently have plaque that breaks off and travels into the small vessels to form

and embolus. Positive remodeling or outward remodeling is more common in women.

7. Define the concept of differential diagnosis and explain how the concept applies to R.K.’s

symptoms: Differential diagnosis includes two disease processes that have similar

characteristics. The main disease process associated with Angina is Myocardial Infarction.

ATI Page 191 states that the “continuum from angina to myocardial infarction is acute

coronary syndrome. Symptoms of acute coronary syndrome are due to an imbalance

between myocardial oxygen supply and demand. Angina pectoris is a warming sign of an

impending acute myocardial infarction. Women and older adults do not always experience

manifestations typically associated with angina or myocardial infarction. These findings are

related to R.K’s initial findings.

CASE STUDY PROGRESS

After some rest, R.K.’s chest pain has subsided, and she tells you she feels much better now. You

review her lab results.

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