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HISTORY

Pt is a 68 y/o Caucasian woman with no previous history of cardiac disease other than

hypertension for the past 8 years. On the day of admission, the Pt was working in her garden

when she felt a dull pressure like discomfort between her shoulder blades. She noted that the

discomfort did not abate when she went into the house to get some water. During the next 10

to 15 minutes, the discomfort worsened, and she noticed that she was getting sweaty and

nauseated. She called the local hospital, and an emergency team arrived at her home. The

patient does not remember anything else until she woke up in the coronary care unit at the

local general hospital. The emergency medical technicians notes indicate that the patient was

unconscious but breathing with a very slow, regular pulse of 36 beats per min (bpm). Her

systolic blood pressure could not be measured by auscultation but was 66 mm Hg by palpation.

She was attached to a portable ECG monitor, and appropriate emergency procedures were

implemented. She was transported to the hospitals emergency room where she was diagnosed

with an acute inferior and posterior myocardial infarction. She was in third degree heart block

with a regular rhythm and a pulse of 34. She was hooked to an external pacing machine and

transferred to the catheterization laboratory for the insertion of a pacemaker. After successful

insertion of the pacemaker, she was admitted to the coronary care unit. Her rhythm normalized

after 24 hours, and the pacemaker was removed. She continued to experience episodes of

angina and to demonstrate signs of left sided heart failure for several days after the initial

infarction. She was referred to physical therapy on day 4 after the initial infarction.

SOCIAL HISTORY

The patient has been a widow for the past 6 years. Her husband died from a heart attack in his

late 50s. She has two daughters who live nearby, and she has four grandchildren of various

ages. She also has two cats and dogs. Both daughters are married and they both have their own

careers. The patient was helping them by providing day care for the two youngest children and

afternoon baby-sitting for the older children. She fears that she wont be able to do thisanymore. She was a full-time homemaker for her entire adult life. The patient is active in her

church and has several female friends in the neighborhood. She plans to return to her home.

According to her daughters, the home has two stories and an attic. The patients bedroom is on

the second floor. Her daughters have both expressed their willingness to have her convalesce in

their residences. Both daughters state that the patient has been in great health all her life. They

think that she has been handling her daily living quite well and believe she can return to her

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previous level of function. The patient has never smoked, but her husband smoked two packs a

day for their entire married life (38 years).

PAST MEDICAL HISTORY

Her medical history is unremarkable except for two normal pregnancies and a hysterectomy inher early 50s. She was diagnosed with hypertension during a routine physical examination

when she was 60, and she has been treated with a variety of medications during the past 8

years. These medications include diuretics, beta-blockers, and most recently angiotensin-

converting enzyme (ACE) inhibitor. In addition to smoking and hypertension, she has the

following risk factors: family history (father and mother both died from heart failure), lack of

exercise (the patient has never exercised regularly), obesity (shes 54 and weighs 170 lbs.) and

elevated cholesterol and triglycerides. There is no history of treatment for high cholesterol. The

cardiologists examination revealed third and fourth heart sounds with a mild systolic murmur

(I/VI) in the mid clavicular line.

Patients condition in the CCU

Patients chief complaints were that the food was awful and she wants to go home. Medications included beta blocker, digitalis, a diuretic, an ACE inhibitor, and an aspirin. (+) Troponin level during admission indicating moderate to large infarction which

already have normalized.

Glucose levels are mildly elevated at 136 mg/dL, and her hematocrit and hemoglobinranges are within normal ranges.

Following cardiac catheterization, findings were: 100% proximal right coronary arteryocclusion, 70% left anterior descending artery occlusion, 30% occlusion of the

circumflex.

Patients ejection fraction was 32 % Patients Left Ventricular end diastolic pressure was 18 mm Hg Chest X-ray showed mild cardiomegaly with some signs of pulmonary edema which has

since resolved.

The patients 3

rd

degree heart block has not returned since removal of the pacemaker.

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OUTPATIENT EXAMINATION/EVALUATION

The patient was referred to outpatient clinic for continued progression of the exercise program

and for patient and family education. If the patient is admitted to the program without a formal

exercise test, then further examination is necessary.

Subjective:

Patient reveals that she has had no episodes of angina and acute shortness of breath. She has been taking the same medications when she was an inpatient, and she has been

walking a couple of times a day in her living room for about 5 minutes without incident.

Heart rate has been below 78 every time she has walked and during other activities.

She remains anxious about her condition and is eager to learn more about how she canreduce her risks for subsequent complications.

She has been referred for a bypass surgery but she doesnt want to proceed at this timebecause of fear and expense.

The next piece of information to be gleaned involves the patients goals. When thepatients are in the hospital, their primary goal is to go home. When they are

outpatients, a clear determination by the clinician of their reason(s) for attending the

program is necessary so that the most advantageous intervention and outcomes can be

ascertained. The patients goals include being able to return to her previous level offunction, which includes babysitting her grandchildren and participating in church

socials without being short of breath. She also relates that she is afraid to do much of

anything at home or for herself because she does not want to experience another

attack.

Finally, another assessment of her exercise tolerance is now needed which in this case ifthe 6 minute walk test. Before the test is conducted, clearance from the referring

physician and the patients informed consent should be obtained. Why should you

conduct a 6-minute walk test?This test has been used extensively to examine patients

with cardiac dysfunction and failure. This test is performed by asking the patient to walkas far as she can travel in 6 minutes. This should be done across a measured, level

surface with close monitoring of the heart rate, blood pressure, ECG symptoms, and

heart sounds.