Comprehensive Myocardial Infarction (MI) Case Study

Patient Chart

Patient Name: James Robert Carter
Date of Birth: 11/08/1962
Age: 62
Gender: Male
Medical Record Number: 20250317
Date of Admission: 03/17/2025
Primary Care Provider: Dr. Emily Thompson

Chief Complaint (CC)

"I have severe chest pain that won’t go away and it’s radiating down my left arm."

History of Present Illness (HPI)

James Carter is a 62-year-old male who presented to the Emergency Department with sudden onset of severe substernal chest pain lasting over 30 minutes. The pain radiates down his left arm and into his jaw. He reports associated symptoms of nausea, shortness of breath, and diaphoresis. He states the pain began while he was watching TV, and it has not improved with rest. He took aspirin 325 mg at home when the pain started, but it did not help.

He has a known history of hypertension, hyperlipidemia, and type 2 diabetes mellitus, and a 30 pack-year smoking history, though he quit 5 years ago.

Past Medical History (PMH)

  • Hypertension (diagnosed 20 years ago)
  • Type 2 Diabetes Mellitus (diagnosed 15 years ago)
  • Hyperlipidemia (diagnosed 10 years ago)
  • Obesity (BMI 31)
  • Coronary Artery Disease (CAD) (diagnosed 5 years ago, no prior MI)

Surgeries & Procedures

  • Cardiac catheterization (4 years ago, single vessel disease)
  • Appendectomy (at age 25)

Allergies

  • None known

Medications

  • Metoprolol 50 mg twice daily (hypertension/CAD)
  • Atorvastatin 40 mg nightly (hyperlipidemia)
  • Metformin 1000 mg twice daily (diabetes)
  • Lisinopril 10 mg daily (hypertension)
  • Aspirin 81 mg daily (CAD prevention)

Family History (FH)

  • Father: Died of myocardial infarction at age 64
  • Mother: Alive, 88, history of hypertension and type 2 diabetes
  • Brother: Alive, 65, history of heart disease and stroke

Social History (SH)

  • Smoking: 30 pack-year history, quit 5 years ago
  • Alcohol: Occasional drinker (1-2 drinks per week)
  • Drug Use: Denies
  • Occupation: Retired truck driver
  • Living Situation: Lives with spouse

Review of Systems (ROS)

  • General: Diaphoretic, reports severe chest pain
  • Cardiovascular: Chest pain, radiation to left arm and jaw, no palpitations
  • Respiratory: Shortness of breath
  • Gastrointestinal: Nausea
  • Neurological: No syncope or focal deficits
  • Musculoskeletal: No joint pain

Physical Assessment Findings

Vital Signs

  • Temperature: 98.6°F (37°C)
  • Heart Rate: 110 bpm, irregular
  • Respiratory Rate: 22 breaths/min
  • Blood Pressure: 156/94 mmHg
  • Oxygen Saturation: 94% on room air

General

  • Appears anxious and diaphoretic

Cardiovascular

  • Tachycardic, irregular rhythm
  • No murmurs or gallops
  • Capillary refill: 3 seconds
  • Peripheral pulses: 2+ bilaterally

Respiratory

  • Slightly labored breathing, clear to auscultation bilaterally

Gastrointestinal

  • Soft, non-tender, no organomegaly

Neurological

  • Alert and oriented x4
  • No focal deficits

Laboratory Results

Basic Metabolic Panel (BMP)

Test Result Reference Range
Sodium 139 mEq/L 135-145 mEq/L
Potassium 4.1 mEq/L 3.5-5.1 mEq/L
Chloride 103 mEq/L 98-107 mEq/L
Bicarbonate 23 mEq/L 22-28 mEq/L
BUN 18 mg/dL 7-20 mg/dL
Creatinine 1.0 mg/dL 0.6-1.2 mg/dL
Glucose (random) 178 mg/dL 70-140 mg/dL

Complete Blood Count (CBC)

Test Result Reference Range
White Blood Cell Count 10.8 x10³/µL 4.0-11.0 x10³/µL
Hemoglobin 14.5 g/dL 12.0-16.0 g/dL
Hematocrit 43% 36-46%
Platelets 240 x10³/µL 150-450 x10³/µL

Cardiac Enzymes

Test Result Reference Range
Troponin I 8.5 ng/mL <0.04 ng/mL
CK-MB 12 ng/mL 0-5 ng/mL

Coagulation Studies

Test Result Reference Range
PT 12.8 sec 11-13.5 sec
INR 1.0 0.8-1.1
aPTT 29 sec 25-35 sec

Diagnostics

  • 12-Lead ECG: ST elevation in leads II, III, aVF (inferior MI)
  • Chest X-ray: No acute pulmonary findings
  • Echocardiogram (pending)

Nursing Diagnoses

  1. Acute Pain related to myocardial ischemia as evidenced by patient report of severe chest pain.
  2. Ineffective Tissue Perfusion (Cardiac) related to occlusion of coronary artery as evidenced by ST elevation and elevated troponin.
  3. Anxiety related to health crisis as evidenced by patient’s restlessness and verbalization of concern.
  4. Risk for Decreased Cardiac Output related to myocardial damage.

Plan of Care (Interventions & Rationale)

  • Administer MONA protocol (Morphine, Oxygen, Nitroglycerin, Aspirin) to relieve pain and improve oxygen delivery.
  • Continuous cardiac monitoring to detect arrhythmias.
  • Obtain serial troponins to track infarction progression.
  • Monitor vital signs closely to detect hemodynamic changes.
  • Prepare for potential cardiac catheterization or thrombolytic therapy.
  • Educate patient on importance of medication adherence, smoking cessation, and cardiac rehabilitation.

Evaluation & Follow-Up

  • Pain relief within 30 minutes after interventions.
  • ST segment resolution post-reperfusion therapy.
  • Patient verbalizes understanding of condition, treatment, and need for follow-up.
  • Follow-up appointment with cardiologist in 1 week.

Discharge Plan

  • Medications: Dual antiplatelet therapy (aspirin + clopidogrel), beta-blocker, statin, ACE inhibitor.
  • Activity: Gradual return to activity, avoid heavy lifting.
  • Diet: Heart-healthy, low sodium, low fat.
  • Cardiac rehabilitation referral.
  • Emergency plan: When to call 911 if symptoms recur.