Patient B is 42 years of age and works as a newspaper editor. He presents to the emergency department complaining of chest pain radiating into both arms, accompanied by diaphoresis and shortness of breath. He has been having episodes of transient substernal and shoulder pain over the past week. He is admitted to the CCU.

Patient B is being treated for hypertension and is currently taking 100 mg metoprolol twice per day. He does not exercise and has smoked a pack of cigarettes daily for 20 years. He reports being under considerable job stress. He is overweight, with a body mass index of 35.

Upon admittance to the CCU, a full physical exam is conducted (Table 5). An ECG shows ST segment depression and T wave inversion consistent with subendocardial ischemia in the inferior and anterior leads. An incomplete left bundle branch block is also noted. Laboratory studies (CBC, urinalysis, and cardiac isoenzyme levels) are all within normal limits, although cardiac isoenzymes are in the upper range.

Based on the results of the assessment, Patient B is diagnosed with:

Patient B stays in the CCU for three days. During that time, serum cardiac enzyme levels and repeat ECGs confirm a diagnosis of subendocardial ischemia rather than MI. Coronary artery angiography is done to clarify the coronary artery anatomy and finds a 35% to 45% occlusion of the left anterior descending artery. The possibility of coronary artery vasospasm is not excluded because no ergonovine trial is done. Repeat evaluation for coronary artery bypass surgery is planned for the future, with conservative medical treatment in the interim.

At discharge, Patient B is prescribed:

Patient C, 44 years of age, is brought to the emergency department by ambulance after collapsing at an airport prior to departing on a business trip. He had eaten a large lunch before going to the airport. During the assessment and initiation of treatment, the patient is anxious to return to work. After several short bursts of ventricular tachycardia cause him to become nauseated and short of breath, Patient C agrees to be admitted to the CCU until he feels better.

About three years ago, Patient C noted chest discomfort unrelated to exertion. He tried without success to relieve the chest discomfort with various over-the-counter antacids. Eventually, the pain subsided and he dismissed it with various rationalizations. Two years ago, an ECG done during a routine physical exam was interpreted as normal. This is his first hospital admission.

Family history is positive for early CHD among the men and type 2 diabetes among the women. There are no family members with renal disease, tuberculosis, or cancer.

Patient C is a vice president for a large advertising agency. His job involves frequent travel and entertainment of clients, and he reports frequently drinking alcohol as part of "doing business." This usually consists of a martini at lunch and two whiskey sours before dinner. He smokes occasionally, especially while working on important business deals. He engages in no regular exercise program but does play racquetball occasionally as part of his business-related social life. He owns a home in an affluent neighborhood with his wife; their lifestyle includes entertaining at home and at their country club. Their three teenaged children attend private schools.

Upon admittance to the CCU, a full physical exam is conducted (Table 6). ECG shows sinus tachycardia with frequent PVCs. The atrial and ventricular rate is 114 bpm, and ST segment elevation and depression are noted. Extensive laboratory studies find:

A second set of serum enzymes shows an LDH of 298 IU/L and a SGOT of 192 IU/L. Urinalysis reveals straw-colored urine with specific gravity of 1.009, pH of 6, and rare white blood cells per high power field. Patient C's ABGs are also assessed (Table 7).

Based on the results of the assessment, Patient C is diagnosed with acute anterior and inferior MI with early carcinogenic shock.

In the emergency department, oxygen is administered at 4 L/minute via a nasal cannula. Patient C is given lidocaine, 100 mg, as a bolus IV; a lidocaine infusion is started at 2 mg/minute. On arrival in the CCU, the patient is noted to have frequent PVCs as well as one period of five ectopic ventricular beats. A 0.5 mg/kg bolus of IV lidocaine is given, and the infusion rate is increased to 4 mg/minute. The nurse instructs Patient C to notify them if he develops numbness or tingling, chest pain, light-headedness, or other discomfort. A portable chest x-ray is done shortly after he arrives in the CCU and shows pulmonary vascular congestion. IV furosemide (Lasix), 20 mg, is administered, and an indwelling urinary catheter is inserted and connected to a urinometer.

One hour after his arrival in the CCU, Patient C's blood pressure is noted to be barely audible at 60/35 mm Hg. An arterial line is placed in the left radial artery, and a pulmonary artery thermodilution catheter is placed via the left subclavian artery.

An infusion of dopamine hydrochloride (400 mg in 500 mL D5W) is begun at 5 mg/kg/minute. Morphine sulfate is titrated intravenously to reduce the patient's pain, anxiety, and dyspnea. Patient C continues to have 10 to 15 PVCs per minute despite the lidocaine infusion continuing at 4 mg/minute. The oxygen is changed to 15 L/minute by mask. Sodium nitroprusside is cautiously administered as an IV infusion of 50 mg in 250 mL D5W at 0.5 mcg/kg/minute. The patient's blood pressure and cardiac output begin to improve.

Patient D, 73 years of age, has a history of severe CHD and is admitted to the hospital with a chief complaint of increasing difficulty with angina pectoris that is not controlled with her current medications.

Six years ago, Patient D had a coronary artery bypass procedure. In the past two years, she has been admitted to the hospital several times with unstable angina. Angiograms were done five years, three years, and one month previously.

Coronary angiography one month ago demonstrated complete occlusion of the main stem of the left coronary artery, with previous grafts to the left anterior descending and circumflex branches; partial occlusion of the left anterior descending graft; complete occlusion of the circumflex graft; complete occlusion of the obtuse marginal branch; and partial occlusion of the right coronary artery. The total occlusion of the obtuse marginal branch and partial occlusion of the right coronary artery had developed since the previous angiograms. Following the most recent angiogram, Patient D experienced a significant hypertensive episode that was successfully treated with dopamine hydrochloride infusion, verapamil, and nitroglycerin ointment.

Patient D's father died at 70 years of age of CHD, and her mother had a history of hypertension and died at 91 years of age following a stroke. She has two brothers, one who died at 60 years of age of CHD and diabetes and another brother (70 years of age) with peripheral vascular disease requiring lower extremity vascular bypass surgery. Patient D does not smoke and drinks very little alcohol.

Upon admittance to the CCU, a full physical exam is conducted (Table 8). An ECG shows changes consistent with old anteroseptal and inferior infarcts as well as lateral ischemia. Laboratory studies (CBC, urinalysis, and cardiac isoenzyme levels) are all within normal limits.

Based on the results of the assessment, Patient D is diagnosed with unstable angina pectoris, known severe CHD (status post-MI), and status post-coronary artery bypass graft surgery, with one graft clotted.

On the day of admission, Patient D's physician orders a propranolol regimen in an effort to control her anginal pain. This is unsuccessful, and after several days, the physician recommends coronary artery bypass graft surgery. Patient D discusses the proposed surgery with her family and agrees it is necessary. She is scheduled for surgery the next day.

During the procedure, the surgeon places grafts from the aorta to the obtuse marginal and circumflex branches of the left coronary artery as well as to the right coronary artery. Following surgery, the patient has an uncomplicated recovery.

She is returned to the CCU with an endotracheal tube and on a continuous mechanical ventilator. She is weaned from the ventilator slowly and extubated the morning of the first postoperative day. However, Patient D is reluctant to turn, deep breathe, or cough. The nurse tries to ensure adequate pain relief before carrying out these postoperative routines and provides encouragement and support. Family members are allowed to help the patient because she coughs better with their help.

Patient D recovers steadily, but due to her debilitation prior to surgery, her progress is slow. She is transferred out of the CCU on the fifth postoperative day.

Patient E is a man, 65 years of age, who presents to the emergency department with a two-day history of high-grade fever with chills. He tells the nurse that he does not feel well and believes he may have the flu. He also complains of "some painful bumps" that appeared on his fingers and toes last night. The patient denies any pain other than the lesions on his fingers and toes. He also denies cough, chest pain, breathing problems, palmar or plantar rashes, and vision problems. He does display mild malaise and some loss of appetite.

Patient E reports having had an infected tooth removed about two weeks ago but does not recall taking any antibiotics prior to or after the procedure. He has a history of asthma since childhood and rheumatic fever twice as a child, with mitral valve replacement two years ago. He was diagnosed with hypertension 20 years previously, type 2 diabetes nine years previously, and chronic obstructive pulmonary disease four years previously. Patient E has a 45 pack-year smoking history, but quit when he was diagnosed with emphysema. He also has a history of alcohol abuse, but quit drinking four years ago and continues to attend Alcoholics Anonymous meetings regularly and is active in his church as an usher and frequent volunteer. He denies IV drug abuse.

The patient's mother died following a stroke at 59 years of age and had ovarian cancer. His father had a history of alcohol abuse and type 2 diabetes and suffered an MI at 54 years of age. He died in his 60s from metastatic pancreatic cancer.

Patient E was married for 43 years and is recently widowed and lives alone. He is the father of four and grandfather of 10. One son lives in the same city, but his other children live in other states. He worked as an insurance salesman before retiring last year. Since then, his monthly income has been derived from Social Security, a retirement account, and a small life insurance benefit following his wife's death. He manages his own medications, has no health insurance, and pays for his medications himself.

He reports an allergy to penicillin. As a result of his diagnoses, Patient E is currently taking several medications:

Upon admittance to the CCU, a full physical exam is conducted (Table 9). An ECG is ordered, and the results are normal. Transthoracic echocardiogram indicates 3-cm vegetation on the aortic valve, but no signs of ventricular hypertrophy or dilation. Several laboratory tests are ordered, the results of which are:

Urinalysis reveals pale yellow, clear urine that is negative for proteinuria and hematuria. A urine toxicology screen was also negative. Three blood cultures obtained over one day are positive for Streptococcus viridans. Based on the results of the assessment, Patient E is diagnosed with infective endocarditis, likely originating from the dental infection and procedure.