Posted: April 18th, 2015

Ischemic Heart Disease

Trevor comes to see the doctor

You are on clinical placement in a general practitioner (GP) office, assisting the practice nurse in taking patient histories and conducting general assessments. Trevor Larkins has come for his appointment.

‘So how are you feeling, Mr Larkins?’ you ask.

‘Fine – I feel absolutely fine. I’m only here because the wife made an appointment.’

‘So what did you want to discuss with the doctor?’

‘Susan – that’s my wife – she’s got in in her head that I need a check up. We go for a walk every morning and she says I shouldn’t get as breathless as I do. She reckons the doc should give me the once over.

‘So how far do you and your wife walk each day?’ you ask Trevor. ‘Is it very far? And do you walk slowly or briskly?’

‘Well, it’s not power walking, that’s for sure.’ Trevor goes on to tell you that he and Susan walk about 200 metres around the block near their home each day, to the shop where he buys his newspaper and his cigarettes.

‘And how many cigarettes would you smoke on average each day?’ you ask.

‘Only the one pack,’ Trevor tells you. ‘I’ve cut down. That’s another thing Susan keeps on about. So here I am – but I don’t know what all the fuss is about.’

Taking Trevor’s history

You and the RN begin your assessment by taking Trevor’s history. This is the information he gives you:

• He is a 61 year old man. He was born in Sydney and lived there until he was 50, when he and his wife, Susan, decided to move to this rural town (around 40,000 residents including a large Indigenous population).
• He and Susan have four children, aged 23, 25, 27 and 30, who all live in Sydney.
• Trevor works as an architect, spending a lot of his work day at his desk. He and Susan like to spend their weekends either relaxing at home or visiting their family.
• Trevor doesn’t really like physical activity and hasn’t played any type of sport since he was a teenager at school. He tells you he is too busy and ‘doesn’t see the point’.
• He tells you he generally doesn’t pay much attention to what he is eating. He says he eats whatever Susan cooks for him and when they go out for dinner (about twice each week), he usually orders steak and chips.
• He was told by a GP a few years ago to ‘get checked out’ for type 2 diabetes mellitus, but he has never followed up.

 

 

Assessing Trevor

You and the nurse begin a full physical assessment of Trevor. Here is some of the information you collect:

Trevor is 172cm tall and weighs 122kg.

Trevor’s vital signs are:

• Blood Pressure (BP) 143/87mmHg
• Heart Rate (HR) 87 beats per minute (at rest, sitting on the examination bed)
• Respiratory Rate (RR) 24 breaths per minute (at rest, sitting on the examination bed)
• Temperature (Temp) 36.6^oC
• Oxygen Saturation (SpO₂) 94% on room air
• Heart sounds are normal: S1 and S2 heard clearly
• Lung fields sound diminished, but clear to bases
• Blood Glucose Level (BGL) 12.4mmol/L (about 4 hours after his last meal).

The doctor’s opinion

With this information, the GP suspects Trevor has Ischaemic Heart Disease (IHD) and decides to send Trevor for a fasting BGL, HbA1C and serum cholesterol tests.

Focus for investigation

What is Ischaemic Heart Disease?

• Describe the aetiology, pathogenesis and clinical manifestations
• Which signs and symptoms can you see in Trevor’s story that fit this disease?

What are the risk factors for IHD?

• Which ones can you find here in Trevor’s history?

What tests can be done to diagnose IHD?
What other information would you like to collect in your assessment of Trevor (remember, you are in a GP office- think of the resources you have available to you there).

What complications (or potential complications) can arise from IHD? Relate these to how they might influence Trevor’s story.

 

A month later

Trevor’s test results were as follows:

• fasting BGL  9.6mmol/L
• HbA1C 7.2%A
• serum cholesterol level 9.1mmol/L

Trevor has now been diagnosed with IHD and type 2 diabetes. He is prescribed atorvastatin 20mg oral daily and advised to manage the diabetes via his diet for the time being.

Focus for investigation

• Why has this medication been prescribed to Trevor?
• What other medication options are available to treat IHD?

Suggested Rereferences:

Brown, D. & Edwards, E. (2013) Lewis’s Medical-Surgical Nursing 3ed Elsevier, Sydney

–       Chapter 32: Nursing management: hypertension

• Focus: Hypertenstion

–       Chapter 33: Nursing management: coronary artery disease and acute coronary syndrome.

• Focus: Coronary Artery Disease pp 854-867
• Note: Table 33-7 Hyperlipidaemia

–       Chapter 4: Health Promotion and Patient Education

• Note: this will help with your written assignment…

Bullock, S. & Hales, M. (2013) Principles of Pathophysiology Pearson, Frenchs Forest

–       Chapter 21: Ischaemic Heart Disease

• Note role of atherosclerosis
• Note figure 21.6: Clinical Snapshot- Ischemic Heart Disease
• Compare and contrast the case study from page 492-495

Bullock, S. & Manias, E. (2014) Fundamentals of Pharmacology Pearson, Frenchs Forest

–       Chapter 45: Medicines used to lower blood lipids

 Further references:

Journal search keywords:

Ischaemic heart disease, coronary artery disease, atherosclerosis, hyperlipidemia

Useful texts:

Berman, A, Snyder, S, et al (2012) Kozier and Erb’s Fundamentals of Nursing 2AustEd Pearson, Frenchs Forest

Bryant, B. & Knights, K. (2011) Pharmacology for Health Professionals 3ed Elsevier, Sydney

Craft, J., Gordon, C., Tiziani, A. et al (2011) Understanding Pathophysiology Elsevier, Sydney

Crisp, J., Taylor, C. et al (2013) Potter and Perry’s Fundamentals of Nursing 4ed Elsevier, Sydney

LeMone, P., Burke, K. et al (2014) Medical-Surgical Nursing: Critical Thinking for Person-Centred Care 2AustEd Pearson, Frenchs Forest

Porth, C. (2011) Essentials of Pathophysiology 3ed Lippincott Williams & Wilkins, Philadephia