Original work, No Plagiarism, Cite, Reference APA, Respond underneath the question (the 3 questions are at the end of the document), concise bulleted answers<\/p>\n
Case Study: Angina and ACS<\/p>\n
After reviewing the case, please provide answers to the questions that follow. Concise, bulleted answers are highly preferred. Points will be removed for lengthy answers.<\/p>\n
1st Visit<\/p>\n
Background:<\/p>\n
NG is a 52-year-old white male reports to clinic with a 1-month history of chest pain and shortness of breath that began after turning over new flower beds for his wife. At first, the pain was heavy, and located in the center of his chest. It resolved when he stopped shoveling and rested. When he tried to dig again, the pain returned. He stopped and asked his son to finish the digging. The pain has not recurred with his normal level of activity but does recur with greater than normal exertion.<\/p>\n
Vitals:<\/p>\n
\u00b7 Blood pressure: 152\/94 mmHg<\/p>\n
\u00b7 Pulse: 94 bpm<\/p>\n
\u00b7 Respiratory rate: 22\/min<\/p>\n
\u00b7 Temperature: 98.6<\/p>\n
\u00b7 Height: 5\u201911\u201d<\/p>\n
\u00b7 Weight: 252 pounds (up 22 pounds since last visit about 2 years ago)<\/p>\n
\u00b7 Chest Pain: 0\/10<\/p>\n
PMH:<\/p>\n
\u00b7 Hypertension<\/p>\n
\u00b7 Tobacco abuse disorder<\/p>\n
\u00b7 Overweight status<\/p>\n
Social History:<\/p>\n
\u00b7 32 pack year history of smoking, currently 1.5 \u2013 2 packs per day<\/p>\n
Current Medications:<\/p>\n
\u00b7 Hydrochlorothiazide 12.5 mg daily<\/p>\n
Fasting Labs:<\/p>\n
Today\u2019s Value<\/p>\n
Normal Range<\/p>\n
Sodium Level (SOD)<\/p>\n
140<\/p>\n
136-146 mMol\/L<\/p>\n
Potassium Level (POT)<\/p>\n
4.2<\/p>\n
3.5-5.0 mMol\/L<\/p>\n
Chloride (CHLOR)<\/p>\n
105<\/p>\n
98-108 mMol\/L<\/p>\n
CO2 (CO2)<\/p>\n
26<\/p>\n
22-34 mMol\/L<\/p>\n
Urea Nitrogen (UN)<\/p>\n
14<\/p>\n
8-20 mg\/dL<\/p>\n
Creatinine Level (CREAT)<\/p>\n
1.0<\/p>\n
0.5-1.0 mg\/dL<\/p>\n
Glucose Level (GLUC)<\/p>\n
152<\/p>\n
73-110 mg\/dL<\/p>\n
Calcium Level (CAL)<\/p>\n
9.6<\/p>\n
8.6-10.3 mg\/dL<\/p>\n
Cholesterol (CHOL)<\/p>\n
248<\/p>\n
1-200 mg\/dL<\/p>\n
Triglycerides (TRIG)<\/p>\n
148<\/p>\n
1-150 mg\/dL<\/p>\n
High Density Lipoprotein Chol (HDL)<\/p>\n
34<\/p>\n
40-60 mg\/dL<\/p>\n
Low Density Lipoprotein Chol (LDLC)<\/p>\n
194<\/p>\n
1-129 mg\/dL<\/p>\n
Hemoglobin A1c<\/p>\n
6.9<\/p>\n
4.2-5.6%<\/p>\n
2nd Visit<\/p>\n
Background:<\/p>\n
A little more than two months later NG reports to clinic with a 1 month history of chest pain and shortness of breath on exertion. He reports that the chest pain comes on when he goes out to smoke and\/or walks the dog, now usually after walking for approximately 1\/2 block. He notes that the pain is probably a little worse if he walks faster or for a longer time. He feels very winded at that time as well. He admits that he has not been able to quit smoking and has stopped trying. To help with the chest pain, he will rest, and the chest pain resolves after approximately 25 minutes. He notes that he has also occasionally had this sort of discomfort in the past, but only when mowing the lawn or shoveling snow or other very strenuous activity, and that it resolved upon stopping. It seems to be that he cannot even do as much as he used to without the pain coming on. He has not treated the pain with any medication to date. He also admits that his diet has been very poor, he has been under a great deal of stress at work, and he has been doing little exercise. He has not wanted to use the nitroglycerin because the one time that he did, so he got a bad headache. His chest pain did improve, but he feels it would have if he rested and not taken the nitroglycerin. He admits that he has not been taking his aspirin daily because he did not feel any better when he took it. He has been taking his metoprolol and atorvastatin as directed. He denies chest pain currently\u2014he is sitting and at rest.<\/p>\n
Objective Data at Visit 2:<\/p>\n
\u00b7 32 pack year history of smoking, currently 2 \u2013 2.5 packs per day<\/p>\n
Vitals: obtained this morning are as follows<\/p>\n
\u00b7 Blood pressure: 149\/90 mmHg<\/p>\n
\u00b7 Pulse: 86 bpm<\/p>\n
\u00b7 Respiratory rate: 22<\/p>\n
\u00b7 Temperature: 98.6<\/p>\n
\u00b7 Height: 5\u201910\u201d<\/p>\n
\u00b7 Weight: 260 pounds (up 8 pounds since last visit)<\/p>\n
\u00b7 Chest Pain: 4\/10 after he walked in from parking lot, now 2\/10 after resting 15 minutes<\/p>\n
Current Medications:<\/p>\n
\u00b7 Hydrochlorothiazide 12.5 mg daily<\/p>\n
\u00b7 Metoprolol tartrate 25 mg twice daily<\/p>\n
\u00b7 ASA 81 mg daily (patient states he has not been taking)<\/p>\n
\u00b7 NTG 0.4 mcg SL prn (used once, but none since)<\/p>\n
\u00b7 Atorvastatin 80 mg daily<\/p>\n
3rd Visit<\/p>\n
Background:<\/p>\n
It is decided that NG should have another stress test. NG\u2019s stress test shows a hypokinetic region of the apical portion of the heart. While undergoing the stress test, he develops severe chest pain and is taken to the hospital. Troponin levels were checked and found to be elevated. He is diagnosed with Acute Coronary Syndrome. A PCI is performed, and a drug eluting stent placed. One week after treatment and release, he is back in clinic for discharge follow up. He also was diagnosed with new onset Type II diabetes and started on metformin. He has had some chest pain since discharge and has used nitroglycerin 2 times. Chest pain resolved on use.<\/p>\n
Objective Data at Visit 3:<\/p>\n
\u00b7 Stopped smoking while in hospital and has not resumed<\/p>\n
Vitals:<\/p>\n
\u00b7 Blood pressure: 149\/92 mmHg<\/p>\n
\u00b7 Pulse: 62 bpm<\/p>\n
\u00b7 Respiratory rate: 22<\/p>\n
\u00b7 Temperature: 98.6<\/p>\n
\u00b7 Height: 5\u201910\u201d<\/p>\n
\u00b7 Weight: 236 pounds<\/p>\n
\u00b7 Chest Pain: 0\/10<\/p>\n
Current Medications:<\/p>\n
\u00b7 Hydrochlorothiazide 12.5 mg daily<\/p>\n
\u00b7 Metoprolol tartrate 50 mg twice daily<\/p>\n
\u00b7 Clopidogrel 75 mg daily<\/p>\n
\u00b7 ASA 81 mg daily<\/p>\n
\u00b7 NTG 0.4 mcg SL prn<\/p>\n
\u00b7 Metformin 500 mg BID<\/p>\n
\u00b7 Atorvastatin 80 mg daily<\/p>\n
Other Studies:<\/p>\n
\u00b7 EF determined to be 38% by TEE<\/p>\n
Fasting Labs:<\/p>\n
Today\u2019s Value<\/p>\n
Normal Range<\/p>\n
Sodium Level (SOD)<\/p>\n
142<\/p>\n
136-146 mMol\/L<\/p>\n
Potassium Level (POT)<\/p>\n
4.1<\/p>\n
3.5-5.0 mMol\/L<\/p>\n
Chloride (CHLOR)<\/p>\n
105<\/p>\n
98-108 mMol\/L<\/p>\n
CO2 (CO2)<\/p>\n
26<\/p>\n
22-34 mMol\/L<\/p>\n
Urea Nitrogen (UN)<\/p>\n
12<\/p>\n
8-20 mg\/dL<\/p>\n
Creatinine Level (CREAT)<\/p>\n
1.0<\/p>\n
0.5-1.0 mg\/dL<\/p>\n
Glucose Level (GLUC)<\/p>\n
131<\/p>\n
73-110 mg\/dL<\/p>\n
Calcium Level (CAL)<\/p>\n
9.6<\/p>\n
8.6-10.3 mg\/dL<\/p>\n
Cholesterol (CHOL)<\/p>\n
252<\/p>\n
1-200 mg\/dL<\/p>\n
Triglycerides (TRIG)<\/p>\n
154<\/p>\n
1-150 mg\/dL<\/p>\n
High Density Lipoprotein Chol (HDL)<\/p>\n
30<\/p>\n
40-60 mg\/dL<\/p>\n
Low Density Lipoprotein Chol (LDLC)<\/p>\n
186<\/p>\n
1-129 mg\/dL<\/p>\n
Hemoglobin A1c<\/p>\n
7.0<\/p>\n
4.2-5.6%<\/p>\n
1. Would prasugrel (Effient) have been an appropriate choice for a P2Y12 inhibitor for this patient? Why?<\/p>\n
0. How long should he be treated with P2Y12 inhibitor therapy?<\/p>\n
0. What risk factors need to be addressed?<\/p>\n","protected":false},"excerpt":{"rendered":"
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