Ehrman5E_HKPA_Chapter04_CaseStudy- John Coggins
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Chapter 4 Case Study
Subjective
Medical History
Ms. WY is a 63 yr old woman with a history of type 2 (adult-onset) diabetes, hypertension, and tobacco use. She first experienced midscapular back pain 3 wk ago while shoveling snow. The pain was grade 2 out of 4 in severity, worse with exertion, improved slightly with rest, and associated with nausea. Two weeks ago, she was hospitalized for 4 d, diagnosed with an ST-
segment elevation myocardial infarction (STEMI). She underwent stent placement to the proximal left anterior descending coronary artery, with vascular access established through the right radial artery. She now complains of shortness of breath on moderate exertion, such as carrying a full laundry basket up one flight of stairs, but is able to go shopping and do general housework.
Medications: Atorvastatin 80 mg/d at bedtime, aspirin 81 mg/d, metoprolol two times 100
mg/d, metformin three times 500 mg/d with meals, clopidogrel 75 mg/d, lisinopril 10 mg/d, and nitroglycerin 0.4 mg sublingual as needed
Allergies: Penicillin, causes a rash
Medical history: Diabetes for 6 yr, hypertension for 10 yr
Family history: Mother had diabetes. Father died of a heart attack at age 62.
Social history: Current smoker (one pack per day), has one alcoholic drink per week, employed as a secretary, married, two adult children, college graduate, reliable transportation.
Lifestyle history: Sedentary with very rare physical exertion. Diet history is notable for skipping breakfast and eating fast food four or five times per week, with one or two servings of fruits and vegetables each day. She averages 6 h of sleep at night, snores heavily, and wakes up most mornings with a mild headache.
Diagnosis
Recent STEMI with stent placement to the proximal left anterior descending artery and mild reduction in left ventricular systolic function
Diabetes
Hypertension
Obesity
Sedentary behavior
Tobacco abuse
Discussion Questions
a.
Based on the medical history, what is the primary disease of concern, and are there any comorbidities?
i.
The primary disease of concern is CVD because patient has 6 out of 8 risk factors for CVD and is/was experiencing major signs of CVD, metabolic. and/or renal disease specifically pain in midscapular back (women sometimes experience midscapular back compared to males for myocardial infarction) and shortness of breath with mild exertion
1
From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology HK
Propel Access, 5th ed.
(Champaign, IL: Human Kinetics, 2023).
ii.
Comorbidities: previous myocardial infarction, mild reduction in left
ventricular systolic function, diabetes, hypertension, and obesity. These
collective morbidities contribute to the primary disease of concern, CVD. b.
Describe the patient’s diagnosis and comorbidities (pathophysiology).
i.
Patient first experienced typical cardiac chest pain and later sustained a recent STEMI with stent placement and is experiencing mild reduction in left ventricular systolic function; Further investigation as to why patient has mild reduction in left ventricular systolic function is recommended because it could potentially be from another underlying issue or lead to another MI event
ii.
Patients also complain of shortness of breath with mild exertion, such as carrying laundry, but can accomplish other ADLs; Further investigation needed to determine exact cause iii.
Patient has obesity and diabetes; both are risk factors for CVD
iv.
Patient has hypertension (risk factor for CVD), no specific value is mentioned in patient’s diagnosis and medical history, so exact measurement will need to be determined v.
Patient has a sedentary lifestyle and regularly smoke; both are risk factors for CVD
vi.
Patient’s family medical history indicates a predisposition to metabolic disorders
Pathophysiology
i.
Recent STEMI with Stent Placement: This indicates blockage of the coronary arteries, resulting in lack of blood flow and oxygen parts of the heart; Stent Placement opens the blockage of the coronary artery to restore
blood flow
ii.
Diabetes: mild state of chronic inflammation of adipose tissue and a state of malnutrition by excess, which leads to a defective hormonal and immune system; inflammatory components, directly and indirectly, related
to major chronic diseases such as diabetes, atherosclerosis, hypertension, and several types of cancer.
iii.
Hypertension: Increases workload on the heart and can damage blood vessels; Over time, resulting to increased heart rate, BP, and inflammation
iv.
Obesity: Excess body mass, particularly adipose tissue and causes inflammation, insulin resistance, dyslipidemia, and an increased risk of cardiovascular disease
v.
Sedentary behavior: contributes to obesity and increases risk of CVD
vi.
Tobacco use: causes the development of atherosclerosis, increases blood pressure, and decreases oxygen delivery to the heart.
c.
What major symptoms or signs are reflective of the disease of concern and comorbidities if applicable?
d.
What are the recommendations for medical clearance to exercise or become physically active? Is an exercise test required?
e.
Are there any absolute or relative contraindications to exercise testing?
f.
Discuss any medications the patient is prescribed and describe the following:
Mode of action and physiological effects
2
From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology HK
Propel Access, 5th ed.
(Champaign, IL: Human Kinetics, 2023).
Indications, usage, and side effects
Influence on exercise and physical activity if applicable
Objective and Laboratory Data
Physical Examination Results
General appearance: Pleasant, alert, and interactive but looks tired. Smells of cigarette smoke.
Vital signs: Blood pressure = 152/87 mmHg, pulse = 48 beats · min
−1
, respiration = 14 breaths/min, body mass = 185 lb (84 kg), height = 64 in. (163 cm), waist circumference =
38 in. (97 cm). Oxygen saturation on room air is 98%.
Cardiovascular
: No carotid bruits, pulses are regular +2 grade, heart is regular rate and rhythm, normal S1 and S2, soft early peaking systolic ejection murmur best heard in the aortic area without radiation, no extra heart sounds, no edema, normal peripheral vascular
exam including the radial artery access site used for the placement of her coronary artery stents
Pulmonary: Breathing comfortably. Mild expiratory wheeze in bilateral lung fields.
Skin: No blisters, wounds, or rashes but has decreased sensation in her feet
Musculoskeletal: Normal gait, joints are normal, good range of motion throughout
Blood Chemistry Test Results
Blood glucose is elevated, but the remainder of the labs are normal.
Other Clinical Diagnostic Test Results
ECG showed normal sinus rhythm with Q waves in leads V1-V3 (consistent with anterior STEMI). Echocardiogram shows an ejection fraction of 40% with anterior wall hypokinesis.
Exercise Test Results
No prior stress testing was done.
Results from this patient’s regular stress ECG exercise test, conducted using the modified Bruce protocol, are listed below. Patient denied chest discomfort, and exercise was limited by fatigue. Total exercise time was 9 min, and estimated peak workload was ~5 METs.
Workloa
d
Time (min)
HR (beats · min
−1
)
BP (mmHg)
RPE
(6-20)
ECG rhythm/arrhythmia
ECG ST segments
Resting
—
70
116/74
—
Sinus rhythm/no arrhythmia
No abnormalities
1.7 at 0%
3
88
120/74
7
None
None
1.7 at 5%
3
100
146/68
12
Sinus tachycardia/no arrhythmia
None
1.7 at 10%
3 to stop
131
154/68
14
None
None
3
From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology HK
Propel Access, 5th ed.
(Champaign, IL: Human Kinetics, 2023).
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Discussion Questions
a.
Are there any results from the physical examination or blood chemistry or other diagnostic test results that may influence any recommendations for exercise or physical activity?
i.
BP level: Patient’s BP level is 152/87 mmHg which is stage 2 hypertension; Exercise intensity could be limited, and with history of STEMI monitoring during exercise will be important
ii.
Heart Rate: Patient’s resting heart rate had two different values 48 beats/min and during exercise testing it was 70 beats/min; One value shows sinus bradycardia while the other is considered a normal HR. Further investigation into patients RHR is advised and determine if they took their medications that day or if medication caused a severe side effect
that requires medical attention. I would recommend for patient to talk to primary doctor because some of the medication have a severe side effect of slow heart, which requires medical attention
iii.
Ejection fraction and anterior wall hypokinesis: The 40% ejection fraction and anterior wall hypokinesis indicate a compromised cardiac function; therefore, exercise recommendations need to be made with caution ensuring exercise type and intensity are appropriate iv.
Pulmonary: Mild expiratory wheeze in bilateral lung fields indicate respiratory concerns that will need to be considered for exercise
v.
Blood glucose levels/ diabetes: Special considerations will need to be considered to maximize safety; Monitoring blood glucose levels will be important before and after exercise
vi.
Decreased sensation in feet: Peripheral neuropathy that will impact balance and sensation during exercise, so non-weight bearing exercise like
cycling should be considered
vii.
Exercise test results: Estimated peak workload of around 5 METs indicates cardiovascular limitations so exercise type and intensity need to be carefully considered b.
Based on the exercise testing results, if applicable, are there any considerations regarding the safety of exercise training for this individual?
i.
Cardiovascular Risks: With history of anterior STEMI, compromised cardiac, and stage 2 hypertension, the patient has an increased risk of CVD
events during exercise, so caution should be taken when creating exercise program to minimize as much risk as possible
ii.
Lung function: Patient’s mild expiratory wheeze in bilateral lung fields is suggestive of respiratory concerns specifically narrowing or obstruction in
airways; will need to check for chronic obstructive pulmonary disease and other pulmonary health conditions to determine safety of exercise
iii.
Creating a highly individualized exercise program: With multiple unique factors (reduced exercise tolerance, compromised cardiac function, peripheral neuropathy, diabetes, and cardiac history) creating an individualized exercise program that promotes safety and improved overall health could prove challenging 4
From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology HK
Propel Access, 5th ed.
(Champaign, IL: Human Kinetics, 2023).
iv.
Continuous monitoring: Continuous monitoring of the patient’s vital signs and symptoms will need to be implemented to maximize safety
v.
Collaboration with Healthcare Team: Will need to closely collaborate with
cardiologists and other members of patient’s healthcare providers to maximize safety and implement all the appropriate precautions Exercise Assessment and Plan
Complete a graded exercise test and begin cardiac rehabilitation with cardiorespiratory training program and associated resistance training program. Initiate counseling about low-fat, low-
calorie diet and refer to registered dietitian for such a diet and a weight loss plan. Strongly encourage smoking cessation and refer patient for specialized treatment.
Discussion Questions
a)
Based on the information provided, what might you consider when determining whether this patient should perform exercise training, and what benefits would you expect to observe?
i)
Factors for determining whether this patient should perform exercise training
(1) Cardiovascular Risks: Patient’s cardiac history, reduced ejection function, elevated BP, and sinus bradycardia increases the risk of Cardiovascular events during exercise. Advise close monitoring of vitals to ensure safety (2) Lung Function: With the patient having mild expiratory wheeze in bilateral lung fields exercise could exacerbate respiratory symptoms making exercise unsafe (3) Blood glucose levels: Monitoring of blood glucose levels before, during and after exercise will be important to maintain safety
(4) Decreased sensation in feet (peripheral neuropathy): will need to determine the severity of peripheral neuropathy to determine how much it impacts exercise including what exercises should be done and exercise safety
(5) Weight loss and Body Composition: Patient is obese, so exercise and diet change are needed to help weight management
(6) Fatigue/exercise tolerance: Exercise was limited by fatigue, and with impaired cardiovascular and wheezing in lung exercise type and intensity needs to not exacerbate symptoms ii)
Benefits expected to observe
(1) Improved Cardiovascular health and function
(2) Improved pulmonary health and function
(3) Improved weight management and body mass
(4) Increased exercise tolerance (most likely only slight)
(5) Improved overall quality of life
b)
Are there any signs, symptoms, medications, or other items listed that would need to be considered when assessing this patient for an exercise training program?
i)
Medications: Exercise should not be unsafe based on medications, but exercise supervision is required because of medications and medical condition
(1) Atorvastatin 80 mg/d at bedtime: lowers total cholesterol and LDLc and dosage falls into appropriate dosage range 10-80 mg/d; does not interact with other medications. Determine is they are experiencing side effects that could impact exercise and if they experience severe side effects such as muscle pain, 5
From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology HK
Propel Access, 5th ed.
(Champaign, IL: Human Kinetics, 2023).
tenderness, weakness or cramps, jaundice, severe stomach pain, weakness in arms
or legs that gets worse after activity or double vision, drooping eyelids, problems swallowing or shortness of breath stop exercise and call their doctor or 111 immediately
(2) Aspirin 81 mg/d: Aspirin is a salicylate and nonsteroidal anti-inflammatory drug; it may also interact with lisinopril. Dosage of aspirin needs to be 81 mg/d because
of combination with clopidogrel. It is not unsafe to take aspirin and lisinopril. Be aware of potential side effects that may impact exercise or make exercise unsafe
(3) Metoprolol two times 100 mg/d: prescription medication for hypertension, AMI, Congestive heart failure, Angina; Dosage and frequency is appropriate and doesn’t exceed 400 mg/d. Does not interact with other medications. Be aware of side of affects that may impact or make exercise unsafe, and if serious side effects
of Metoprolol (hives, difficulty breathing, swelling of the face, lips, tongue, or throat, very slow heartbeats, lightheadedness, shortness of breath, swelling, rapid weight gain, and cold feeling in the hands and feet) stop exercise and have them notify doctor or 111.
(4) Metformin three times 500 mg/d with meals: Prescription medication to treat diabetes; it decreases hepatic glucose production, decreases GI glucose absorption, and increases target cell insulin sensitivity. It is intended as an adjunct
to improve glycemic control in adults with type 2 diabetes, and dosage is within the typical range. Be aware of potential side effects that impact exercise or make exercise unsafe; Metformin does not interact with other their other medications
(5) Clopidogrel 75 mg/d: Used to prevent heart attacks and strokes in persons with
heart disease (recent heart attack), recent stroke, or blood circulation disease
(peripheral vascular disease), and to keep blood vessels open and prevent blood
clots after certain procedures (such as cardiac stent). According to NHS.UK
dosage in combination with aspirin is correct 75 mg/day orally in combination
with aspirin 162-325 mg/day and then 81-162 mg/day. Be aware of potential side
effects that impact exercise or make exercise unsafe and side effects that require
medical attention; Clopidogrel does not interact with other medications
(6) Lisinopril 10 mg/d: Prescription medication used to treat high blood pressure (hypertension); dosage is correct. Medication does not interact with other medications; Beware of potential side effects that impact exercise or make exercise unsafe and side effects that require medical attention
(7) Nitroglycerin 0.4 mg as needed: This medication is used to prevent angina; dosage is correct according to NHS.UK. Beware of potential side effects that impact exercise or make exercise unsafe and side effects that require medical attention
ii)
Cardiovascular History: Close monitoring will need to be established because they have increased risk of cardiovascular events during exercise
iii) Exercise test results: Exercise tolerance is extremely low, so due to age and exercise test results making a creative exercise program will important
iv)
RHR: Resting heart Rate was abnormally low so medical clearance and communication with primary doctor about severe symptoms will need to be done before exercise prescription can start
6
From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology HK
Propel Access, 5th ed.
(Champaign, IL: Human Kinetics, 2023).
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
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v)
Blood glucose levels: Monitoring blood glucose before, during, and after exercise will be important for safety
vi)
Respiratory function: With potential respiratory issues certain exercises and intensities may cause exacerbated symptoms so modifications may be needed during sessions
vii)Peripheral Neuropathy: Decreased sensation in the feet may impact balance and safety depending on severity of exercise, so non-weight bearing exercises should be highly considered
viii)
Lifestyle factors: Providing assistance to help patient quit smoking will be important to improve overall cardiovascular and respiratory health
ix)
Willingness and understanding to change lifestyle: Health promotion models will be needed to be used to help promote adherence to exercise program
c)
Develop a 12 wk exercise prescription for cardiorespiratory, resistance, and range of motion training if applicable. Use the FITT principle when developing your prescription.
d)
Discuss issues that might affect this individual’s ability to begin and adhere to exercise training.
e)
What considerations might affect decisions for exercise workload or intensity progression?
f)
Based on the subject’s medical history and test results, identify areas for which the patient should be further educated (e.g., weight control, diet modification). Are there other resources that you might use?
7
From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology HK
Propel Access, 5th ed.
(Champaign, IL: Human Kinetics, 2023).