• crushing chest pain

• radiating pain to jaw and upper left arm

• increasing dyspnea (feels breathless when walking short distance) + orthopnea

objective:

• pale and diaphoretic

• HR: 100bpm

• BP: 130/90 (high diastolic)

• RR: 26 breaths per min

• saturation: 90%

• cyanotic lips and extremities

• crackles heard in bilateral bases

• ensure continuous monitoring of vital signs

• regularly assess for signs of hypotension, tachycardia or respiratory distress

• observe/assess symptoms of blood clot, i.e., Edema, chest pain, warmth, redness, headache (pain assessment).

• evaluate for chest pain using pain assessment

• monitor for signs of fluid overload

• assess for side effects of medication

2. oxygen therapy

   - monitor for signs of oxygen toxicity or hypoventilation

   - adjust oxygen therapy based on arterial blood gases or pulse oximetry

   
   

3. fluid restriction

   • strictly adhere to the fluid restriction

   • monitor daily fluid intake / output

   
   

4. Patient Safety and Education

   • educate Mr Lee about his medication, side effects, and when to seek help (e.g., worsening chest pain, SOB)

   
   

• advance age of 68

• male

modifiable factors

- hypertension

- hyperlipidemia - cholesterol boarder line high 5.7

LDL-C ( bad cholesterol) 3.9 - borderline high

-reduce physical activity

-incompliance to medication

• Possibly due to his Myocardial Infarction that he received 1 year ago

• Failure to comply with medication

Radiation of pain to jaw and left upper limb:

• Possibly due to his Myocardial Infarction that he received 1 year ago

• Possibly radiated from the angina he sustained from the MI, causing pain to be felt at regional area.

SpO2: 90%, Breathless, RR: 26 and experiencing increasing dyspnoea, and crackles heard during asculatation.

• High RR from vitals, High usage of Accessory Muscles.

• Heart Failure (MI), possible left sided heart failure, results in backlog of blood and pressure to be built up in his pulmonary veins and capillaries, causing fluid overload in his alveoli.

• reduced efficiency of gaseous exchange in his alveoli

Pale and Diaphoretic:

• poor blood circulation to body’s extremities.

• Diaphoretic: Excessive Sweating due to his usage of accessory muscles to breath.

• possibly due to high heart rate too.

Cyanotic lips and extremities, and cold skin, HR 100 beats/mins:

• Poorer circulation of blood to extremities.

• Higher HR seen possibly due to body’s response to reduced contractility of the heart due to his MI.

Myocardial Infarction one year ago

Hypertension and hyperlipidemia

Radiation of pain to jaw and left upper arm

____

Usually, left-sided heart failure is caused by systolic (or pumping) dysfunction.

This is typically due to some kind of damage to the myocardium, which means it can’t contract as forcefully and pump blood as efficiently.

Ischemic heart disease caused by coronary artery atherosclerosis, or plaque buildup, is the most common cause. Less blood and oxygen gets through the coronary artery to the heart tissue, which damages the myocardium.

The coronary blocked completely and the person has a heart attack, they might be left with scar tissue that doesn’t contract at all, which again means the heart can’t contract as forcefully.

This suggest that he is having inflammation of the heart walls, high troponin level suggest there is heart muscles damage, which might cause heart attack.