Subjective
Mark, a 48 year-old male, presents to the office with mild-to-moderate chest pressure with radiation to his back. Mark reports that he was awakened from sleep at 0700 with chest pressure. Initially described as soreness across his anterior chest and through to his back. He rates his pain +6/10. He felt as though if he could just belch, he would feel better. His wife drove him to the office to be here when it opened at 0900. She tried to convince Mark to go to the emergency room, but he emphatically refused, insisting on going to the office first. Upon arrival to the office, you take Mark back to an examination room and instruct the receptionist to call 911.

Past medical/surgical history: Diabetes mellitus type 2

Family history: He has a family history of premature coronary artery disease. His father died of acute myocardial infarction (AMI) at age 45. One brother died of AMI at age 49.

Social history: He has smoked for 25 years but has reduced his smoking to 1 pack per day since his brother’s death 2 years ago. He has put on 25 pounds in the past 2 years and is generally sedentary

Medications: Metformin XR 500mg daily, Last A1C was 7.4

Allergies: Latex

Objective

General: Anxious and shows Levine’s sign as you enter the office room. He is slightly diaphoretic.
Vital signs: BP 192/96, P: 102, RR-22, T-98.8, SpO2 is 90%
ECG: ST segment depression and T wave inversion in leads II and III
CV: Heart tones are muffled with an S3 gallop. Hands and feet are cool to touch. Radial pulses are 2+. Pedal and posterior tibial pulses are 1+. Neck vein distention of 5cm with HOB at 90 degrees.
Respiratory: Rhonchi in upper lobes bilaterally and a non-productive cough
Abdomen: Positive bowel sounds in all 4 quadrants, soft, non-tender, no masses felt.

The provider sent the patient immediately to the Emergency Department. Upon arrival and within 2 hours of arrival for care, troponin was 6 ng/dl, Chemistry panel: Na, K, CL were WNL, BUN 20, Creatinine 0.8, serum glucose 189.

Question answers should be based on evidence found in readings and from peer-reviewed literature. At least two sources must be used and cited in APA format for each question. Only one source can be a textbook. Resources should generally be within 5 years unless you are explaining the pathophysiology of a disease or providing pertinent background information.

Discussion Questions:

1. Describe the similarities and differences of necrosis and apoptosis in regards to the above clinical scenario and diagnosis.
2. What is the role of hydrostatic and oncotic pressure in regulation of blood pressure for this patient?
3. Explain the role of free radicals and myocardial death