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Case Study #1

**Subjective Medical History:**

- **Patient:** Ms. WY, 63-year-old woman
- **Medical Conditions:** Diabetes, hypertension, tobacco use
- **Recent Events:**
- 3 weeks ago: Experienced vague to mild midscapular back pain while shoveling snow; pain caused nausea, worsened with exertion, improved with rest
- 2 weeks ago: Hospitalized for 4 days, diagnosed with ST-segment elevation myocardial infarction (STEMI), stent placed in the left anterior descending coronary artery
- **Current Symptoms:** Shortness of breath on moderate exertion (e.g., carrying a full laundry basket up one flight of stairs), but can shop and perform general housework

- **Medications:**
- Atorvastatin 80 mg daily at bedtime
- Aspirin 81 mg daily
- Metoprolol 100 mg twice daily
- Metformin 500 mg three times per day with meals
- Clopidogrel 75 mg daily
- Lisinopril 10 mg daily
- Nitroglycerin 0.4 mg sublingual as needed

- **Allergies:** Penicillin (causes a rash)

- **Medical History:** Diabetes for 6 years, hypertension for 10 years

- **Family History:**
- Mother had diabetes
- Father died of a heart attack at age 62

- **Social History:**
- Current smoker (one pack per day)
- Consumes one alcoholic drink per week
- Employed as a secretary
- Married, with two adult children
- College graduate
- Has reliable transportation

- **Lifestyle History:**
- Sedentary lifestyle with very rare physical exertion
- Diet notable for skipping breakfast, eating fast food four or five times per week
- Consumes one or two servings of fruits and vegetables daily
- Averages 6 hours of sleep per night, snores heavily, wakes up with headaches

**Objective and Laboratory Data:**

- **Physical Examination:**
- **General Appearance:** Pleasant, alert, interactive, appears tired, smells of cigarette smoke
- **Vital Signs:**
- Blood pressure: 152/87 mmHg
- Pulse: 48 beats/min
- Respiration: 14 breaths/min
- Body mass: 185 lb (84 kg)
- Height: 5 ft 4 in. (163 cm)
- Waist circumference: 38 in.
- Oxygen saturation: 98% on room air
- **Cardiovascular:**
- No carotid bruits
- Regular +2 grade pulses
- Regular heart 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 or edema
- Normal peripheral vascular exam
- **Pulmonary:** Breathing comfortably, mild expiratory wheeze in bilateral lung fields
- **Skin:** No blisters, wounds, or rashes, decreased sensation in feet
- **Musculoskeletal:** Normal gait, normal joints, good range of motion

- **Laboratory Data and Testing:**
- Normal ECG
- Echocardiogram: Ejection fraction of 40%, anterior wall hypokinesis
- Elevated blood glucose
- No prior stress testing

**Assessment and Plan:**

- Recent STEMI with mild reduction in left ventricular systolic function and stent placement
- Diabetes
- Hypertension
- Obesity
- Sedentary behavior
- Tobacco abuse

**Recommendations:**

1. Complete a graded exercise test and begin cardiac rehabilitation with a cardiorespiratory training program and associated resistance training program.
2. Initiate counseling about a low-fat, low-calorie diet and refer to a registered dietitian for a weight loss plan.
3. Strongly encourage smoking cessation and refer the patient for specialized treatment.

**Discussion Questions:**

1. Classify Ms. WY's chest pain at the time of her hospitalization as typical, atypical, or non-cardiac. What features of the chest pain are missing? Why might these be important features?
2. What is her functional class? What is her estimated aerobic capacity? Explain your answer.
3. Calculate her BMI. Does she have gynecoid or android features? How does her obesity contribute to her medical problems?
4. Are any red flags present on the clinical evaluation that require contacting, at least by telephone, her physician or another supervising physician before exercise testing?
5. What prevention issues need to be addressed in the near future?

Answer :

Final answer:

Based on the description of her condition, Ms. W.Y's chest pain was typical angina. Her functional class is III, suggesting low aerobic capacity and her lifestyle factors notably obesity and sedentary behavior coupled with controlled issues in her blood pressure and blood sugar levels warrant immediate medical and lifestyle changes, including dietary modifications, cessation of smoking, and introduction of an exercise regimen.

Explanation:

Ms. W.Y's chest pain during her hospitalization can be classified as typical angina. Typical angina, or angina pectoris, is characterized by pain in the mid to upper back, often associated with nausea and worsening with exertion, exactly the symptoms Ms. W.Y experienced. The pain is due to an insufficient supply of blood to the heart muscle, often caused by narrowing of the coronary arteries, a common occurrence in patients suffering from MI (myocardial infarction).

Her functional class is III which means she experiences symptoms of heart disease even with everyday physical activities. This can be determined by the fact that she has shortness of breath carrying a laundry basket up a flight of stairs. Therefore, we can estimate her aerobic capacity to be low, as regular, moderate physical activity causes strain.

Ms. W.Y's Body Mass Index (BMI) can be calculated using the following formula: weight(kg)/height²(m). Given her weight as 84 kg and height as 1.63m, we can calculate her BMI as 31.6. With a waist circumference of 38 inches and BMI above 30, android or upper body obesity is present, which contributes to her diabetes and cardiovascular disease.

The significant rise in her blood pressure is a red flag which warrants notifying her physician prior to conducting exercise testing. This can be a sign of unstable hypertension which requires medical intervention.

Lastly, prevention efforts should be directed towards lifestyle modifications which include smoking cessation, dietary changes to a low calorie, low-fat diet, weight loss, initiation of an exercise regimen under professional supervision and optimal control of blood glucose levels and blood pressure.

To answer the question about reflecting and transmitting waves in an ideal plasma, we will leverage the tenets of wave intensity and propagation, optical constants, and the theory of electromagnetic radiation.

Firstly, since the intensity of a wave is directly linked to the amplitude squared, we can denote the intensity of the incident wave as |A|², reflected wave as |B|², and transmitted wave as |C|². Following the question, we are interested in the square of the ratio of the reflected to incident wave electric amplitude, or |B|²/|A|², denoted as r².

It's important to note that when w>>Wp, the plasma can be treated as a dielectric, and laws of optics apply, notably the Fresnel equations. Now, the reflection coefficient (r²) for a plane electromagnetic wave incident from vacuum on a dielectric (plasma) can be expressed in terms of the refractive index of the plasma. Given that the refractive index is approximately 1 - Wp²/(2w²) for w>>Wp, substituting this into the Fresnel equation simplifies r² to a Taylor series expansion that brings it to the form r² = C w/Wp.

By equating coefficients from both sides we can solve for C = 1/2, hence r² = 1/2 (Wp/w) is the found relationship.


Learn more about Chest Pain here:

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