Christina Hammack and Cash Thomas
Acute Coronary Syndrome (ACS)
Myocardial Infarction (MI)
JoAnn Smith, 68 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Fluid and Electrolyte Balance
2. Clinical Judgment
3. Communication
4. Collaboration
, Christina Hammack and Cash Thomas
UNFOLDING Reasoning Case Study-STUDENT
Acute Coronary Syndrome/Acute MI
History of Present Problem:
JoAnn Smith is a 68-year-old woman who presents to the emergency department (ED) after having three days of progressive
weakness. She denies chest pain, but admits to shortness of breath (SOB) that increases with activity. She also has
epigastric pain with nausea that has been intermittent for 20-30 minutes over the last three days. She reports that her
epigastric pain has gotten worse and is now radiating into her neck. Her husband called 9-1-1 and she was transported to
the hospital by emergency medical services (EMS).
Personal/Social History:
JoAnn is a recently retired math teacher who continues to substitute teach part-time. She is physically active and lives
independently with her spouse in her own home. She has smoked 1 pack per day the past 40 years. JoAnn appears anxious
and immediately asks repeatedly for her husband upon arrival.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
d3 days of progressive weakness dWomen can present with alternative symptoms than men when
Denies chest pain, reports epigastric pain with experiencing a myocardial infarction so it is important to consider them in
nausea radiating to her neck and shortness of this context as opposed to ruling out MI since it is not the “typical”
breath presentation
RELEVANT Data from Social History: Clinical Significance:
Lives with a spouse Patient has a support person who lives with her and can help provider care
Heavy smoker, 40 year history which is important to keep them involved in the care as appropriate (and
Anxious appearing legally - patient gives consent to share information). Significant smoking
history means patient has had prolonged vasoconstriction and diminished
lung capacity; smoking also leads to heart disease. Anxiety can alter vital
signs like increased heart rate and blood pressure.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medications treat which conditions? Draw lines to connect)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
● Diabetes mellitus type II 1. Iron Sulfate 325 1. Iron supplement 1. Replace iron
● Hypertension mg PO daily 2. ACE inhibitor 2. Reduce BP
● Hyperlipidemia 2. Lisinopril 5 mg PO daily 3. Antihyperlipidemic 3. Reduce cholesterol
● Cerebral vascular 3. Simvastatin 20 mg PO daily (-statin) 4. Reduce platelets/prevent
accident (CVA) with no 4. Aspirin 81 mg PO daily 4. Salicylate clotting
residual deficits 5. Clopidogrel 75 mg PO daily 5. Platelet aggregation 5. Reduce platelets/prevent
● Gastro-esophageal reflux 6. Omeprazole 20 mg PO daily inhibitor clotting
disease (GERD) 7. Metformin 500 mg PO bid 6. Proton pump inhibitor 6. Reduces stomach acidity
● Anemia-Iron deficiency 7. Biguanide antidiabetic 7. Reduces blood glucose
levels
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?
Acute Coronary Syndrome (ACS)
Myocardial Infarction (MI)
JoAnn Smith, 68 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Fluid and Electrolyte Balance
2. Clinical Judgment
3. Communication
4. Collaboration
, Christina Hammack and Cash Thomas
UNFOLDING Reasoning Case Study-STUDENT
Acute Coronary Syndrome/Acute MI
History of Present Problem:
JoAnn Smith is a 68-year-old woman who presents to the emergency department (ED) after having three days of progressive
weakness. She denies chest pain, but admits to shortness of breath (SOB) that increases with activity. She also has
epigastric pain with nausea that has been intermittent for 20-30 minutes over the last three days. She reports that her
epigastric pain has gotten worse and is now radiating into her neck. Her husband called 9-1-1 and she was transported to
the hospital by emergency medical services (EMS).
Personal/Social History:
JoAnn is a recently retired math teacher who continues to substitute teach part-time. She is physically active and lives
independently with her spouse in her own home. She has smoked 1 pack per day the past 40 years. JoAnn appears anxious
and immediately asks repeatedly for her husband upon arrival.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
d3 days of progressive weakness dWomen can present with alternative symptoms than men when
Denies chest pain, reports epigastric pain with experiencing a myocardial infarction so it is important to consider them in
nausea radiating to her neck and shortness of this context as opposed to ruling out MI since it is not the “typical”
breath presentation
RELEVANT Data from Social History: Clinical Significance:
Lives with a spouse Patient has a support person who lives with her and can help provider care
Heavy smoker, 40 year history which is important to keep them involved in the care as appropriate (and
Anxious appearing legally - patient gives consent to share information). Significant smoking
history means patient has had prolonged vasoconstriction and diminished
lung capacity; smoking also leads to heart disease. Anxiety can alter vital
signs like increased heart rate and blood pressure.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medications treat which conditions? Draw lines to connect)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
● Diabetes mellitus type II 1. Iron Sulfate 325 1. Iron supplement 1. Replace iron
● Hypertension mg PO daily 2. ACE inhibitor 2. Reduce BP
● Hyperlipidemia 2. Lisinopril 5 mg PO daily 3. Antihyperlipidemic 3. Reduce cholesterol
● Cerebral vascular 3. Simvastatin 20 mg PO daily (-statin) 4. Reduce platelets/prevent
accident (CVA) with no 4. Aspirin 81 mg PO daily 4. Salicylate clotting
residual deficits 5. Clopidogrel 75 mg PO daily 5. Platelet aggregation 5. Reduce platelets/prevent
● Gastro-esophageal reflux 6. Omeprazole 20 mg PO daily inhibitor clotting
disease (GERD) 7. Metformin 500 mg PO bid 6. Proton pump inhibitor 6. Reduces stomach acidity
● Anemia-Iron deficiency 7. Biguanide antidiabetic 7. Reduces blood glucose
levels
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?
