CASE STUDY - MMW 2 ( 12/ 06/2016 - 18/06/2016)

JP AGNES PETER
PSL JANUARI 2016
KJMT

ACUTE CORONARY SYNDROME ( ACS) / TOPHI GOUTY

Encik E.J / 67 yrs old / Male / Jawa / Pensioner

13/06/16 @ 10am
Direct admission from A & E
-An ex smoker (smoked for 30 years / 1 pack per day / ceased smoking since 3
years ago.
-An ex alcohol consumer (Quit 3 years ago)
Allergy : Drug/Food - NIL
U/L; 1. CCF

2. HPT
3.IHD
4. Gouty Arthritis
Old Medications:
T.
T.
T.
T.
P/W:

T. Aspirin 150mg OD
Clopidopril 75mg OD
Imdur 30mg OD
Peridropil 2mg OD
Frusemide 20mg OD

T.
T.
T.
T.
T.

Digoxin
Allupurinol 150mg OD
Colchicine 25mg OD
Calcium Lactate 600mg OD
X Calcitriol 0.25mcg OD

1.

Left sided chest pain since 5am on 13/6/2016.

Sharp pain lasted from 5am to 7am ( Pain score 3/10)
O/w: Diaphoresis / vomit/ dizziness/ palpitation
Pt claimed did not take S/L GTN because not being given during
previous
prescription.
2.

Fever x 1/7
Due to ruptured tophi gouty
O/w: UTI - p/w yellowish
URTI
bowel incontinent
HX of fall/ trauma
vomit / abd pain
Headache
pre syncopes attack / syncope

Vital signs : Bp 167/107 mmHg

Pulse 121/ min
Temp 37.5
Resp 22/min
SPO2 100% under room air
Post surgical history: NIL
Family history: Malignancy / heart disease in family.
Social history: Married and blessed with 8 children
Wife was a housewife
2 children working (odd job)
3 children OKU
Patient partially supported by children
Currently:

chest pain / palpitation

vomiting
Comfortable under room air.

Physical Examination:
Lungs : Clear
Abd : soft / non tender
Right ankle : gouty tophi
Discharge (whitish)
bleeding, foul smells

CXR : Cardiomegaly
ECG : Sinus Rythym
TAll I, T II, III, AVF,
Q Wave V4, V5, V6, II, III, AVF
IX:
HB 13.5
TWBC 10.7
Plt 391
ESR73
PCV 403

IMP:

1. HPT emergency
2. Treast as ACS
3. Acute Gouty Arthritis

Plan:

1.
2.
3.
4.
5.
6.

Monitor vital sign

DXT QID
I/O Charting
ECG Od/ Upon chest pain
Refer ortho for rupture of gouty tophi
Cont old medication

ACUTE CORONARY SYNDROME

Definition
Acute coronary syndrome (ACS) refers to any group of symptoms attibuted to
obstruction of the coronary arteries. The most common symptom prompting
diagnosis of ACS is chest pain, often radiating to the left arm or angle of the
jaw, pressure like i character, and associated with nausea and sweating. ACS
usually occurs as aresult of one of three problems : ST elevation myocardial
infarction (30), non-ST elevation myocardial infarction (25), OR unstable
angina (38).
What causes ACS (Pathofisiology)

Acute coronary syndrome is typically caused by coronary heart disease.

Coronary heart disease , also called heart disease, is caused by
artherosclerosis, or hardening of the arteries.
Artherosclerosis causes a substance called plaque to build up in the coronary
arteries. Plaques causes angina by narrowing the arteries.
Signs & Symptoms
The cardinal symptom of decreased blood flow to the heart is chest pain,
experienced as tightness around the chest and radiating to the left arm and
the angle of the jaw.This may be associated with diaphoresis (sweating),
nausea and vomiting, as well as shortness of breath. In many cases, the
sensation is atypical, with pain experienced in different ways or even being
completely absent. Some may report palpitations, anxiety or a sense of
impending doom and a feeling of being acutely ill.
Diagnosis
1. Electrocardogram
In the setting of acute chest pain, the ecg is the investigation that most
reliably distinguishes between various causes. If this indicates acute heart
damage (elevation in the ST segmeent, new left bundle branch block),
treatment for heart attack in the form of angioplasty of thrombolysis is
indicated immediately. It is not possible to immediately distinguish between
unstable angina and NSTEMI.
2. Imaging and blood tests
Chest x-ray, blood tests (including myocardial markers such as Troponin I or T,
and H-FABP and/or a D-dimer if a pulmonary embolism is suspected), and
telemetry (monitoring of the heart rhythm).
Treatment
People with presumed ACS are typically treated with aspirin, clopidogrel or
ticagrelor, nitroglycerin and if the chest discomfort persists morphine.

Nursing Diagnosis
#1. Chest pain related to tissue ischemia (coronary artery occlusion)
Objective: Patient verbalize relief/control of chest pain after medication
administered.

Nursing intervention
1. Do pain assessment by monitoring the characteristic of pain through
patients complaint,
restlessness, face expressions and Pain score chart.
2. Advise patient to report pain immediately so that immediate actions can be
taken.
3. CRIB to minimized the pain.
4. Teach patient to do relaxation techniques: deep and slow breathing which is
helpful in
decreasing perception and response to pain.
5. Check vital signs before and after GTN Tablet was given to patient to
monitor existence of
Hypotension and respiratory depression.
Nursing Diagnosis
#2. Activity intolerance related to imbalance between myocardial oxygen
supply and demand.
Objective:Progressive increase in tolerance for activity with normal breathing
pattern.
Nursing intervention
1. Encourage patient to rest between ativities to reduces myocardial workload
and oxygen
consumption.
2. Advice patient to avoid abdominal pressures as this will increased the
consumption of
oxygen and burdens the heart.
3. Teach patient to do relaxation techniques: deep and slow breathing which is
helpful in
decreasing perception and response to pain.
4.Refer to cardiac rehabilitation which can provide the patient bthe continue
support and
additional supervision in recovery and wellness process.
5. Advice patient to CRIB.