Reference no: EM133726852

Case Study A

Albert, an apartment superintendent, grabbed a quick cup of coffee and then put on his coat to shovel snow off the front sidewalk. He is 56 years old and has experienced two episodes of angina over the past 3 years. This time when he was shoveling the snow, he felt palpitations in his chest. It was as though his heart had stopped and then began to beat rapidly as if to catch up. Afraid of what he was feeling, he went inside and called for an ambulance. When the paramedics arrived, they took an ECG and told Albert he was going to be fine. He was taken to hospital to be seen by an emergency physician and was released later that afternoon.

Question 1. The ECG taken by the paramedics showed Albert was experiencing premature ventricular contractions. In general terms, how do PVCs appear on an ECG? Differentiate between the cause of unifocal and multifocal PVCs. What factors contributed to the onset of PVCs in Albert's situation?

Question 2. Describe the physiologic events in PVC. How is cardiac output disrupted with the presence of PVCs?

Question 3. Because of Albert's history, his PVCs leave him at risk for events such as ventricular tachycardia or ventricular fibrillation. What is the correlation between PVCs and ventricular tachycardia? Compare and contrast ventricular tachycardia and ventricular fibrillation. How are they managed? Why are they particularly dangerous?

Case Study B

Kelly had just finished dinner with her husband, and they had just sat down to watch television. She is 72 years old and has had a history of angina. Shortly after they sat down, Kelly said she had indigestion and went to take some antacid tablets. An hour later, she began to feel warm, restless, and anxious. Her husband noticed she was looking pale and said he would take her to a nearby walk-in clinic. By the time they arrived, Kelly said her left arm and shoulder were sore.

Suspecting Kelly was having a heart attack, her husband turned the car around and rushed her to the hospital. On arrival to the emergency department, an ECG was performed and Kelly was administered oxygen, heparin, and nitroglycerin.

Question 1. An ECG of Kelly's heart demonstrated an elevated ST segment. What is an ST segment elevation? What is meant when an ST elevation demonstrates "reciprocal changes". What are the physiologic effects of myocardial ischemia that produce this finding specifically discussing transmural ischemia vs subendocardial ischemia. What would you suspect on an ekg with ST segment elevations in leads 2, 3, & aVF versus an ekg with ST segments in 2,3, aVL, v3,v4 v,5 in a febrile patient?

Question 2. What are the benefits of administering heparin, P2Y12 inhibitors, nitroglycerin, and oxygen in the early management of STEMI? In what STEMI patients would nitroglycerin be contraindicated and why? (hint list pharmacological contraindications and a specific type of MI in which nitrates are contraindicated) Oxygen should be applied only if needed to keep saturation levels above what percentage? What is the physiological rational for this?

Question 3. What is the inflammatory response in the postinfarction recovery period? Why will Kelly's heart function be compromised after her STEMI?

Case Study C

Karen was called at work by a woman at the local day care center. She told Karen to come and pick up her son because he was not feeling well. Her son, 3½-year-old Billy, had been feeling tired and achy when he woke up. While at day care, his cheeks had become red, and he was warm to touch. He did not want to play with his friends, and by the time Karen arrived, he was crying. Later that afternoon, Billy's condition worsened. He had fever, chills, arthralgias, a sore throat, runny nose, and a dry hacking cough. Suspecting Billy had influenza, Karen wrapped him up and took him to the community health care clinic.

Question 1. Why did Billy's presentation lead Karen to think he had influenza and not a cold? Why is it important to medically evaluate and diagnose a potential influenza infection? Would the treatment differ if Billy did have Rhinovirus which causes the common cold?

Question 2. In the event that Billy did not have a cough or sore throat but rather presented with nasal congestion, fever, and a frontal headache made worse when bending forward, what condition would you suspect? How would you treat this? At what point would antibiotics be indicated?

Question 3. Billy may be at risk at contracting secondary bacterial pneumonia. Why is this so? What symptoms and exam findings would lead you to believe that Billy's illness was related to a lower respiratory infection such as pneumonia? If he was diagnosed would pneumonia how would you intend to treat it?

Case Study D

Brandon and his mother live in an urban community housing complex. The building is worn down and dirty from the urban dust, cockroaches, and mold. Brandon is 5 years of age and has suffered from asthma for the last 2 years. One evening, his mother poured him some milk and put him to bed. Shortly afterward, Brandon woke up wheezing and coughing. As he gasped for air, he became more and more anxious. His mother ran for his inhaler, but he was too upset and restless to use it. Brandon's skin became moist with sweat, and as he began to tire, his wheezing became quieter. His mother called 911 and waited anxiously for the ambulance to arrive.

Question 1. Brandon uses a corticosteroid inhaler for the management of his asthma. What is the mechanism of action of this drug? How is its action different from the ? 2 -agonist inhalants? When would Brandon use one versus the other?

Question 2. Why does someone with severe asthma become physically fatigued during a prolonged attack? What are the physiologic events that occur during an attack?

Question 3. One of the complications of respiratory fatigue is the development of hypercapnia. How does the body compensate for an increase in CO 2 ? What are the effects of hypercapnia