Running head: UNSTABLE ANGINA AND BREATHLESSNESS

The University of Jordan – Faculty of Nursing

Case Study

The Association Between Unstable Angina and Breathlessness.

Presented by:

Fatima zghoul 8210936

Dr: Amani khalil

UNSTABLE ANGINA AND BREATHLESSNESS. 2
Introduction

Angina is a restricted of blood supplied to heart muscles due to narrowing of the arteries

connected to the heart and reduce the amount of oxygen to the heart muscle. Unstable angina

(acute coronary syndrome) characterized by symptoms that isn’t relieved by rest or nitroglycerin,

causes chest pain with little physical exertion, may get worse over time and can lead to a heart

attack, so unstable angina should be treated as an emergency case (Brunner. 2010). ”Dyspnea is a

subjective experience of breathing discomfort that consists of qualitatively distinct sensations

that vary in intensity in patients with lung and heart diseases.” (Figarska, Boezen, & Vonk,

2012). Dyspnea is one of symptoms that associated with greater mortality in the general

population (Santos, Kitzman, Matsushita, Loehr, Sueta, & Shah 2016). Unstable angina

frequently presents with chest pain associated with dypnea, thus this paper will present the case

presentation, physical examination, and explore the relationship between unstable angina and

breathlessness according to previous literature discussion.

Chief complain

G.S 58 years old female patient admitted to Jordan University Hospital on the 12th of

MAY 2022, patient complained of severe heaviness chest pain 7/10 on Numerical Rating Scale

(NRS) pain scale, radiated to left shoulder, aggravated by movements and activity, not alleviating

by rest, associated with sweaty and productive cough since two days duration, she also

complained of breathlessness, since one week duration.

Patient profile

Past medical history, patient had hypertension since 15 years, diabetes mellitus since 18

years, and ischemic heart disease since 10 years. She is a smoker 2 packet daily since 20 years;

by calculating pack, years of smoking patient smoked 40 pack/years. Not alcoholic, and not

known to have any allergies. Past surgical history; left hip fixation since 12 years. Past procedure
UNSTABLE ANGINA AND BREATHLESSNESS. 3
was three times percutaneous coronary intervention with multiple stents in right coronary artery

and left anterior descending during last 10 years, the last one was before one month. She is a

housewife and lives with her daughter and husband. When assess effect of diseases on her life,

patient said:

‫ يعني بمشي للتواليت وبوصل المطبخ بطبخ الطبخة لحالي اما شغل‬,‫"انا بقوم بحالي بس ما بقدر على شغل البيت‬

"‫ حركتي خفيفة وما بحب اطلع برا البيت النه نفسي بتعب وبحس جسمي هزالن‬..‫البيت على بنتي‬

.For the family history, check appendix 1

History of present illness

Patient admitted to emergency room, after complained severe heaviness chest pain 7/10

on Numerical Rating Scale (NRS) pain scale, associated with sweaty, productive cough with

small amount white sputum since two days duration. She also complained of breathlessness,

since one-week duration. Episodes of shortness of breath started since one week, no specific time

with rest and without; according to MRC breathlessness scale the patient was graded with the

grade 4 which states that the patient stops after walking 100 meters, or a few minutes, on the

level. She diagnosed as unstable angina, admitted to CCU for cardiac catheterization surgery,

successful percutaneous coronary intervention (PCI) of right coronary artery applied, using one

stent , then she transfered to medical floor ,. Patient non-adherent to her medications, sometimes

she missed the doses of insulin injection or hypertensive tablet.

UNSTABLE ANGINA AND BREATHLESSNESS. 4
Psychosocial aspect

Patient was smiling when I introduced my self to her, she was welcoming, she reported

that she is very stressed because she is had another heart catheterization again, she was anxious,

patient verbalized that:

‫ ما بهون علي اغلب بناتي وال افكر بيوم انه ممكن يبقو لحالهم خاصة لما افكر انه ممكن بيوم‬,‫"انا مريضة وجوزي مريض‬

‫ عدا عن الوضع المادي سيء النه‬,‫ صح انا علمتهم بس بحس دايما انه ناقصهم اشي‬,‫نموت ونتركهم وما في الهم اخ يسندهم‬

".‫ مصاريف الدوا غالية كتير وكل واحد منا اله كمشة ادوية‬... ‫زوجي شغلو قليل النه مريض وتعبان‬

Based on that, patient had anxiety, fear, and helplessness

General examination and systemic review

General survey

Weight: 50 kgs , height: 158 cm. Patient is conscious, oriented and looks tired.

Vital signs on the admission: Temperature = 37.2 C, heart rate = 96 beat per minute, respiratory

rate = 19 breath per minuets, blood pressure = 126/85 mmhg , pain 7\10.

Nutritional assessment

Patient’s BMI: 20 kg/m2 ( Normal weight ). During her stay in hospital the diet was

controlled low salt and diabetes mellitus diet, she eats from 2-3 meals during the day, she doesn’t

do exercise. Patient said that:

, ‫ انا طبيغة اكلي خفيف واخر اسبوعين قلت شهيتي مع التعب والمرض ما بيجي على بالي آكل‬,‫"باكل وجبتين صغار باليوم‬

."‫ وما باكل فواكة ابدا النه ما بحبها من زمان‬,‫مش كتير بلتزم بحمية السكري والضغط باكل من الموجود‬

Patient had poor appetite, and decreased upon hospitalization. Based on what patient said, she

had nutritional imbalance.

UNSTABLE ANGINA AND BREATHLESSNESS. 5
Sleep pattern

Patient sleeps for 5-6 hours at night; she takes afternoon nap once daily. No changes upon

hospitalization.

Skin, hair, and nails

Patient skin was intact, pale in color, no moles or lesions. Skin was dry, smooth, and

warm with good skin turgor, no edema. Patient’s hair distributed, color is appropriate to age

(black to gray), no lesions or masses upon palpation. Nails are pink in color, no signs of

clubbing, smooth, capillary refill less than 2 seconds.

Eyes

Eyebrows are bilaterally and move symmetrically, eyelids: the skin is intact no swelling,

or redness, or lesions, or discharge, eyelashes are present and distributed evenly bilateral.

Conjunctiva pale in color no lesions or swelling bilaterally, sclera white. Eye balls are aligned

normally in their sockets, no exophthalmos.

Head and Neck

No head injury or headache, normochephalic and midline. Neck is symmetrical, full range

of motion, no signs of lymphadenopathy or masses, trachea midline, thyroid tissue was palpable

during swallowing, no bruit sound. Carotid pulse was smooth and strength +2.

Ears

Even color, intact skin, no lesions or tenderness, symmetric bilateral, no ear discharge. As

patient say, no tinnitus, vertigo or otalgia. Whispered words are heard bilaterally. No Otoscope to

assess external canal and tympanic membrane.

UNSTABLE ANGINA AND BREATHLESSNESS. 6
Nose

Midline, no history of inflammation, discharge, lesions, obstruction, deformity, epistaxis,

allergy, or sinus pain.

Mouth and throat

Mouth: lips are pink in color with cracking, moist, no lesions, teeth present in the upper

and lower jaw, straight, evenly spaces and clean. The gum is intact, no swelling, no bleeding,

spongy. Tongue pink in color and even, saliva is present, no lesions or ulcers. Gag reflex present

(intact vagus and glossopharyngeal nerves), no dysphagia or hoarseness. Buccal mucosa is pink,

smooth and moist. Uvula is present in midline, throat: tonsil is +1 (visible). Ask patient to stick

out her tongue, it is protrude in the midline (intact hypoglossal nerve), at the same time ask

patient to say (ahhh), uvula rise in the midline (intact vagus nerve).

Respiratory system

Chest is symmetric bilateral, symmetric chest expansion, effortless breath, no use of

accessory muscles, normal intense of tactile fremitus, no tenderness, lumps or lesions, resonance

sound was heard in the interspaces, all 3 breathing sounds were heard without any adventitious

sounds or limitation (bronchial, Broncho vesicular, vesicular). Patient mentioned that she had

breathlessness since one week before she admitted to hospital, grade 4, productive cough with

small amount white sputum since two days duration. No orthopnea.

Cardiac System

Upon inspection, the apical pulse was visible at 5th intercostal space anterior to

midclavicular line, Palpable with a size of 2cm, amplitude: short, gentle tap, duration: short, no

heavy or thrill. Heart valves were heard at, Right 2nd intercostal space: aortic, left 2nd intercostal

space: pulmonary, left lower sternal border: tricuspid, Left 5th intercostal space: mitral. S1: was
UNSTABLE ANGINA AND BREATHLESSNESS. 7
heard at the apex of the heart with the carotid artery pulse. S2: was heard on the base. No extra

heart sounds S3, S4, or murmurs. Heart rate when examine the patient was 89 beat/minute.

Breast and regional lymph nodes

No swelling, discharge, or rash, symmetric bilateral, skin of the breast was smooth and

even in color, nipples protruded and symmetric bilateral, no lumps or cyst upon palpation the

both breasts. No swelling, inflammation or discharge, no lymphadenopathy.

Renal system

Both kidneys were not palpable; no bruit over renal arteries, Foley’s catheter is inserted.

GFR = 115 ml/min/1.73 m2, calculated by, MDRD equation: 186 x (Creat / 88.4)-1.154 x (Age)

0.203 x (0.742 if female) x (1.210 if black), indicate normal kidney functions.

Abdomen

Flat, umbilicus midline, inverted with no signs of inflammation, no scars, distention, or

ascites, no lesions or masses upon palpation, approximately 28 bowel sound/ min. palpation and

percussion of the liver and spleen could not be obtained. 4/4

Investigations 2/2

Chest X ray, that showed clear chest, electrocardiogram indicate sinus rhythm, heart rate

was 96 beat/minute on admission, echocardiogram showed ejection fraction= 35% that indicate

heart pumping ability is low, heart failure. Cardiac catheterization performed on 13 th of MAY

2022, showed 80% stenosis of right coronary artery and patent old multiple stents. Check

appendix 2 for lab result.

Problems list
Patient had sleep disturbance, nutritional deficit, anxiety, impaired physical mobility,
activity intolerance, non-adherence to medications.
UNSTABLE ANGINA AND BREATHLESSNESS. 8
Health promotion
Patient reported that sometimes she missed the dose intentionally and other times non
intentionally, because she could not control large account of pills, poor recall, multiple
instructions, cost of medication so patient could not pay the treatment (financial wise), and
sometimes forgetting to take it, she reducing the dosing frequency or number of medications and
did not be encouraged to visit doctor appointment. Therefore, health promotion for patient focus
on non-adherence to some medications, and advice patient to write information that they receive
from doctor, make alarms/ reminders, combining medications together in one place (Pillbox) and
ask her daughter to help and remind the patient, educate patient about the importance of
medications and possible side effect, and modifying patient behaviour.

Medications treatment and health promotion3/3

Check appendix 3.

Risk Factors

Risk factors include having diabetes and hypertension, not doing enough exercise and

lack of physical activity, a family history of angina and other heart problems, age, being a

smoker, previous heart attack.

Discussion

Patient who did not complain of cardiopulmonary disease, the association between

breathlessness and incident of heart diseases is unclear yet (Santos, Kitzman, Matsushita, Loehr,

Sueta, & Shah 2016). According to previous literature, most patients with unstable angina would

likely experience chest pain or dyspnea even after treatment (shammas, shammas, keyes, duske,

Kelly, & jerin, 2015). My patient applied catheterization before one month with inserted stent,

after 3 weeks she complained of chest pain associated with dyspnea again.

Study showed that patients, who reported mild to severe intensity dyspnea, are in higher

risk with incident of heart failure and myocardial infarction, and death (Santos, Kitzman,

Matsushita, Loehr, Sueta, & Shah 2016). They also mentioned that obesity, age, low physical

activity levels, excess exposure to stressors and active smoking, play a role in having shortness
UNSTABLE ANGINA AND BREATHLESSNESS. 9
of breath (Santos, Kitzman, Matsushita, Loehr, Sueta, & Shah 2016). My patient had many risk

factors that aggravated the dyspnea. 5/5

Problems list

Patient had sleep disturbance, nutritional deficit, anxiety, impaired physical mobility,

activity intolerance, non-adherence to medications.

Health promotion

Patient reported that sometimes she missed the dose intentionally and other times non

intentionally, because she could not control large account of pills, poor recall, multiple

instructions, cost of medication so patient could not pay the treatment (financial wise), and

sometimes forgetting to take it, she reducing the dosing frequency or number of medications and

did not be encouraged to visit doctor appointment. Therefore, health promotion for patient focus

on non-adherence to some medications, and advice patient to write information that they receive

from doctor, make alarms/ reminders, combining medications together in one place (Pillbox) and

ask her daughter to help and remind the patient, educate patient about the importance of

medications and possible side effect, and modifying patient behaviour.

Conclusion

G.S 58 years old female patient admitted to Jordan University Hospital on the 12th of

MAY 2022 , patient complained of severe heaviness chest pain and breathlessness, cardiac

catheterization performed and one stent implanted, then transferred to medical floor. Dyspnea is

common symptom that associated with most patient complain of angina as reported on literature.

1/1
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References 0.5

Figarska, S. M., Boezen, H. M., & Vonk, J. M. (2012). Dyspnea severity, changes in

dyspnea status and mortality in the general population: the Vlagtwedde/Vlaardingen study.

European journal of epidemiology, 27(11), 867-876.

Santos, M., Kitzman, D. W., Matsushita, K., Loehr, L., Sueta, C. A., & Shah, A. M.

(2016). Prognostic importance of dyspnea for cardiovascular outcomes and mortality in persons

without prevalent cardiopulmonary disease: The Atherosclerosis Risk in Communities Study.

PloS one, 11(10), e0165111.

Shammas, N. W., Shammas, G. A., Keyes, K., Duske, S., Kelly, R., & Jerin, M. (2015).

Ranolazine versus placebo in patients with ischemic cardiomyopathy and persistent chest pain or

dyspnea despite optimal medical and revascularization therapy: randomized, double-blind

crossover pilot study. Therapeutics and clinical risk management, 11, 469.
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Appendix 1
Family history
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Appendix 2

Lab results - 12th of MAY 2022

Test name Patient result Normal value Interpretation

RBS 376 mg/dl 70-120 Hyperglycemia

Na 138 meq/l 135-145 Normal

K 4.3 meq/l 3.5-5.3 Normal

Urea 25 mg/dl 7-18 Normal

Creatinine 0.4 mg/dl 0.5-1.2 Normal

Cl 100 mg/dl 98-106 Normal

Phosphorus 3.4 mg/dl 2.5-4.5 Normal

Mg 1.9 mg/dl 1.7 to 2.2 Normal

Calcium 9.9 mg/dl 8.5-10.5 Normal

CK-MB 17 IU/L 5-52 Normal

CPK 19 IU/L 22- 189 Normal

Troponine I Negative Less than 0.01 Negative

CBC Hb&Ht: 15/44.3 12-16 Increased Hb with

smoking.
WBC: 7.33 3000-10000

Platelet: 213 150000-450000

PT/ INR 14.9/ 1.15 second 11-14 sec/ 0.8-1.2 Normal

PTT 27.5 second 25-35 Normal

hbA1c 12.3 % 6.5% or higher poorer control of

indicate diabetes. blood glucose levels

BNP Less than 10 ng/ml Less than 0.01 Heart failure

UNSTABLE ANGINA AND BREATHLESSNESS. 14
Appendix 3

Medications
Medication Name Dose Route Frequency

Omeprazole 40mg P.O 1*1

ASA 100mg P.O 1*1

Plavix 75mg P.O 1*1

Atrovast 40mg P.O 1*1

Concor 2.5mg P.O 1*1

Brilinta 90mg P.O 1*2

Clexane 80mg S.C 1*2

Lantus 25 U S.C 1*1

Actrapid 8U S.C 1*3

N/S 0.9% 100ml/hr I.V Infusion