Assignment Task

Case Study

1. Acute Coronary Syndrome

Develop a concept map that explains the pathophysiological processes underpinning Charles’ medical history of rheumatic heart disease, obesity, Type 2 diabetes mellitus, hypertension, and hyperlipidaemia, and how these processes lead to his health problems.

The following information relates to the Assessment Task.

1. Concept map.

Charles (he/him) is a 58-year-old Aboriginal man with severe shortness of breath, brought by an ambulance to the emergency department. He has a past medical history of childhood rheumatic fever which progressed into rheumatic heart disease. Four years ago, he was diagnosed with Type 2 diabetes mellitus and was commenced on metformin. Charles is 172cm tall and weighs 106 kg. His Body Mass Index (BMI) is 35.8, waist-to-hip ratio is > 1.0. For many years prior to his current presentation, he has suffered from hypertension and hyperlipidaemia, for which he has been taking aspirin, losartan, amlodipine, and atorvastatin.

Over the past two weeks, Charles has complained of increasing of shortness of breath while walking and has noted some swelling in his feet and ankles. In this time, he has also been unable to lie flat in bed and has resorted to use three pillows to prop him up to sleep in an upright position. Last night, Charles’ wife heard him struggling to breathe and found him leaning against the ensuite bathroom doorway, looking ‘blue’. She immediately called an ambulance.

On the arrival of paramedics, he was sitting in his recliner chair gasping for breath. Paramedics noted he was peripherally cyanosed with a blood pressure of 145/93 mmHg and heart rate 105 beats per minute. His skin was cool and clammy. Chest auscultation revealed widespread crackles bilaterally from base to apices and scattered inspiratory and expiratory wheezes. His initial SpO2 (on room air) was 75% and he was complaining of jaw, neck, and left shoulder pain.

Explain the pathophysiology that relates to each of his signs, symptoms, and test results.

2. Written component

After arrival at the emergency department, he is triaged to a resuscitation bay where he presents with the following observations.

On physical assessment, his observations and results are as follows:

• Anxious with mildly restless movements not aggressive or vigorous
• Glasgow Coma Scale 14 (E4V4M6), verbally confused to place and time
• Pupils equal and reactive to light
• Temperature 37.9°C
• Blood pressure 128/80 mmHg, GTN patch in situ
• Jugular venous pressure elevated
• Pulse regular, not easily palpated radially
• Heart rate 125 beats per minute
• Skin cool, pale, diaphoretic
• Bilateral lower limbs pitting oedema to knees and abdominal ascites.
• Respiratory rate 30 breaths per min with increased work of breathing indicated by accessory muscle use and fatigue.
• SpO2 94% on High Flow Nasal Prongs of 30L/min with a fraction of inspired oxygen (FiO2) 0.6 gave an arterial blood gas: pH 7.30, PaO2 82 mmHg, PaCO2 36 mmHg, HCO3 18mmol/L, lactate 4.0 mmol/L, indicating he has a metabolic acidosis.
• Widespread inspiratory and expiratory crackles, expectorating pink frothy sputum.
• Mild nausea.
• Complains of new retrosternal chest pain, in addition to jaw, neck, shoulder pain, severity rated with a 9/10 pain score on the numeric pain rating scale

Investigations: Charles’ 12 lead electrocardiograph (ECG) and chest X-ray (CXR) soon after arrival at hospital

ECG interpretation: Evidence of severe acute ischaemia in the anterior chest leads consistent with myocardial infarction (STEMI), indicating occlusion of the left anterior descending artery.

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