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XI. PATHOPHYSIOLOGY

Medical Diagnosis

Angina Pectoris, Unstable; Diabetes mellitus type 2 – poorly controlled; Obesity; HPN 2; Hypertensive Cardiovascular
Disease(HCVD); Left Ventricular Hypertrophy (LVH); Anxiety Disorder

Definition

Angina Pectoris, Unstable - Unstable angina occurs when the narrowing becomes so severe that not enough blood gets through to keep
the heart functioning normally, even at rest. The atherosclerotic plaque may rupture in unstable angina, allowing blood clots to precipitate and
further decrease the lumen of the coronary vessel. This explains why an unstable angina appears to be independent of activity. Sometimes the
artery can become almost completely blocked. It may occur unpredictably at rest which may be a serious indicator of an impending heart attack.

Diabetes Mellitus type II - occurs when the pancreas produces insufficient amounts of the hormone insulin and/or the body’s tissues
become resistant to normal or even high levels of insulin.

Hypertensive Cardiovascular Disease (HCVD) - also known as hypertensive heart disease occurs due to the complication of hypertension
or high blood pressure. In this condition the workload of the heart is increased manifold and with time this causes the heart muscles to thicken. The
heart continues pumping blood against this increased pressure and over a period of time the left ventricle of the heart enlarges and this in turn
causes the blood pumped by heart to reduce.

Left Ventricular Hypertrophy (LVH) - Left ventricular hypertrophy (LVH) is the thickening of the myocardium (muscle) of the left ventricle of
the heart caused by increased afterload and hypertension.

Hypertension II- Hypertension is a chronic medical condition in which the blood pressure is elevated.

Obesity - is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health,
leading to reduced life expectancy. Body mass index (BMI), which compares weight and height, is used to define a person as overweight (pre-
obese) when their BMI is between 25 kg/m2 and 30 kg/m2 and obese when it is greater than 30 kg/m2. (http://en.wikipedia.org/wiki/Obesity)

Anxiety Disorder – The anxiety disorders are a group of mental disturbances characterized by anxiety as a central or core symptom.
Anxiety is associated with a wide range of physical illnesses, medication side effects, and other psychiatric disorders.
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Schematic Diagram
Predisposing
Age- 73 years old
Hereditary- HPN, DM Precipitating
Gender- female >HPN (37 yrs old; usual BP 140/90; highest BP is 200/110mmHg)
Hx of Cholecystectomy (NMMC; 1995) >Inc. serum Cholesterol level: 231mg/dL
Menopause (starts at age 42 years old; Menarche starts at age 13 yrs.old.) >Lack of exercise/activity
DM II (1999; usual glucose level: 140-160mg/dL; highest level: 300mg/dL) >Obesity (BMI of 27 kg/m2, IBW: 48.96kg)

Increase shearing force of the arterial wall by the condition


of the blood

Nonspecific injury to arterial wall


(endothelial injury) in the
coronary artery
Diagnostic:
CBC:
Eosinophils-16.4%(0.00-
6.00) Desquamation of endothelial lining and
stimulation of Mast cells to produce
inflammation
Diagnostic:
Blood Chemistry:
Cholesterol-231 mg/dl (0-200 Increase permeability/adhesion molecules,
mg/dl) Lipids (LDL, VLDL) and activation of platelets
Triglycerides-191 mg/dL (0-150 assimilation into the area
mg/dl)

Oxidized LDL attracts monocytes and


Medication: macrophages to the site and plaques begin to
>Atorvastatin Calcium (Lipitor)- form from cells and smooth muscle cells
80mg 1 tab OD @ HS
develop to form foam cells into thrombus
(Antilipidemics)
>Enoxaparine Sodium
(Lovenox)-o.6ml SC q12 Diagnostic:
(Antilipemics) Atherosclerosi >X-Ray Report (Chest AP- Sitting)
>Aspirin s Impressions:
Medication:
(Aspilet EC)-80mg 1tab od Atherosclerosis thoracic aorta.
>Amlodipine Besylate (Norvasc)-
(Nonopioid analgesics and > Color Flow Doppler
Rupture of atherosclerotic plaque 50mg 1 tab OD (Calcium-channel
antipyretics; antiplatelet) Conclusion:
(cap) and Increase adhesion of blockers; Antianginals)
>Clopidogrel (Platexan) a) Segmental wall motion abnormality
>Nitroglycerin (Glyceryl
75mg/tab, 4tabs now, then OD these molecules and increase indicative of coronary artery disease Signs/ symptoms:
Signs/ Trinitrate)-10mg Patch
(Adenosine diphosphate (ADP) thrombus/blood clot formation b) Aortic and mitral scleroses. Right& left subcostal
symptoms:
Coronary Ischemia and Ischemia (Nitrates/Vasodilators;
receptor antagonist c) Aortic regurgitation, 1+ margin chest pain-5-6/10
>Cold, Antianginals)
of tissue in theDiagnostic:
region supplied by d) Mitral regurgitation, trivial pain scale; pain occur
Clammy skin Medication: >Isosorbide Mononitrate (Imdur)
Diagnostic: the and
artery >ECG tracing: Interventions:even during exertion or
Occlusion stenosis/narrowing of the
>prolonged/d 30mg 1 tab OD
Clinical Chemistry:
Signs/ symptoms: ST-depression & > Metoprolol Tartrate >Obtained a 12 lead heaviness
at rest; ECG as and
coronary artery and Tleads
Signs/ to coronary
ecreased (Nitrates/Vasodilators;
Decreased Calcium
>decreased capillary refill of 5 wave (Toprol-XL) 50mg 1tab prescribed tightness of chest with
vasoconstriction Antianginals)
8.3
secsmg/dl Interventions: symptoms: inversion capillary refillBID
Diagnostic: Signs/ symptoms:
(beta-adrenergic >Administered O2 inhalation
dyspnea; via nasal
pain radiates
Signs/ Interventions:
Signs/ of and
5 seconds >Aspirin(Aspilet EC) 80mg 1tab
(8.4
>RR:– 26
10.2 mg/dl)
cpm; tachypneic >O2 therapy viasymptoms:
nasal >Jugular Increase
vein demand >Clinical
for oxygen Clinical Chemistry:
glucose Dysrhythmias(bradycardia;
blockers,
in the cannula at 2L/min
up to the neck and chin;
symptoms: cannula at >O2 therapy via Interventions:
>tachycardia; >increased
Urea od (Nonopioid analgesics)
Decreased
>dyspnea 2L/min distention
Peripheral
tissues andAltered torepolarization
Chemistry:
leads diminished of nitrogen-
myocardial PR:49-59bpm;
Anti-dysrhythmics) tachycardia; >Advised to perform
Anaerobic deep
metabolism
guarding breathing
behavior, facial
>bradycardia; nasal cannula at NPO
PR:130-150bpm
Increased (JVD)(Sept.4- BP of22mg/dl (7-PR >Diazepam (Valium)-5mg 1 tab
Cardiac Increase
Stimulation
>use of accessory of sympathetic
muscles to atvasoconstriction
8cm
oxygenation, Hypokalemia
theCellular
and
myocardium that
hypoxia andcanaltered cell130-150bpm);
>Spironoloctone(Aldac
BID (Anxiolytics)
Stimulation Increase
ofcaused
exercises cardiacLactic
sensory
andgrimace;
used
by Acid
of nerve
productionof
pursed-lip
increased
tachycarsia
Decreased Increase
myocardialPR: 49-59bpm
release of 2L/min
>palpitations
nervous system to stimulate preload 5,2009)
noted except 3.0 mmoL/L 170/110mmH
17mg/dL) palpitations;
tone) 25mg dizziness
1tab OD breathing technique
breathe oxygen
Output decreased blood lead flow
to decreased endings to transmit
with kinins,
demand to for
the
potassium
central
O2
130-150bpm; ions,
nervous
& glucose
mild
Decreased left ventricular >Elevated
Increased HOB P.O medsmembrane
Heart
integrity
Increased after 5.1 g
> Metoprolol Tartrate (Toprol-XL) Unstable Angina
contractility
norepinephrine
adrenal medullaand
needs
>nasal flaring to the kidneyscardiac (3.5-output
(Potassium Sparing system>maintained
50mg 1tab BID (beta-adrenergic to cause relaxing body
prostaglandins
pain
in the anxiety; environment
tissues/hypoxia
Pectoris weakness
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Renin (released from kidneys) to


split off angiotensinogen to form
Medication: angiotensin I
>Losartan Potassium
(Cozaar)-100mg 1tab OD
(Angiotensin II antagonists) Angiotensin-converting enzyme (ACE)
>Captopril(Capoten)-25mg ½ removes and converts Angiotensin I into
tab BID (Angiotensin II Angiotensin II which promotes
Antidiuretic hormone
antagonists) vasoconstriction
Sodium retention
released from by
Angiotensin
kidneys and IIpromotes
hypothalamus stimulates
an
to increase
adrenal
reabsorption ofrelease
cortex
increased plasmawater by
aldosterone
osmotic to
kidneys pressure
increased blood
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Medication:
>Spironoloctone
(Aldactone)
25mg 1 tab OD (Distal
Tubule Diuretics/
Potassium Sparing
Diuretics)

Constipation
prior to
admission
(resolved Sept
1,2009)

Medication: Increased blood Overloading of blood in


Semma cone (Senokot)-30ml pressure the ventricles of the
OD PO heart
Lactulose (Chephulac)-30ml
od PO
Signs/ symptoms:
Diarrhea – resolved >BP- Excessive stretch and
(Sept. 3, 2009) 170/110mmHg(hypertensive) decreased contraction
>temp-36.8°C occur
>Dizziness(10 days prior to
admission until assessment
day
>faintness(10days prior to Increase
Interventions:
admission) workload of the
Hold laxatives for BM≥
2xday heart
COMPLICATIONS:
as indicated Myocardial Infarction
Diagnostic: Dysrhythmias
>Echocardiography Thickening of the cardiac Cardiogenic shock
Conclusion: muscle that leads to Left Pulmonary embolism
Concentric left Ventricular Hypertrophy Recurrent
ventricular Myocardial Infarction
hypertrophy with left Ventricular
ventricular diastolic aneurysms
dysfunction Hypertensive Rupture of the heart
Cardiovascular Pericarditis
Disease (HCVD) Death