History of Chief Complaint: Mr. P is a 61-year-old who colla…

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Histоry оf Chief Cоmplаint: Mr. P is а 61-yeаr-old who collapsed at work and was transported to the ER by ambulance where 12 Lead ECG showed ST elevations in leads II, III, with reciprocal changes anteriorly, indicating inferior wall ischemia.  He was given nitroglycerin which resulted in partial, but not complete resolution of the chest pain. He subsequently had a cardiac catheterization which showed a RCA occlusion and a stent was placed in his RCA, resulting in gradual resolution of the chest pain. An echocardiogram was performed during his admission which showed an Ejection fraction of 40-45% with inferior wall hypokinesis.  Pt was discharged home with orders to have PFT’s and Cardiac Rehabilitation. 6 weeks post the myocardial infarction, patient underwent a Bruce Protocol stress test in preparation for enrolling in cardiac rehab and PFT’s.  He presents to Outpatient Cardiac Rehab for evaluation . PMH: occasional gastric reflux Medications:  Metoprolol succinate, Ticagrelor, Valsartan, Rosuvastatin, zantac as needed, Nitroglycerin sublingual and aspirin. Social History/Habits: Married, lives in 2nd floor apartment. Works fulltime in Buildings and Grounds at local University.  Has 2 adult sons who live out of state.  Heavy smoker of 3ppd x 35 years, quitting 6 weeks ago. Reports 5-6 glasses of wine/week.  No regular form of exercise outside of work. Since discharge from Acute Care, pt has been walking at a fairly light level of exertion for 20 minutes. Ht: 5’9”   Wt 175   BMI 25.8 Labs: WBC 6.0   RBC 3.60   Hgb 12.1   HCT 34.6   BUN 33    Cr 1.3 PFTs: FVC= 80% predicted FEV1 = 58% predicted FEV1/FVC% = 68%   Exercise Stress Test: Bruce protocol Baseline EKG strip @ rest was NSR (see below) The patient developed isolated PVC’s during the latter part of exercise beginning at a HR of 110, but without repetitive forms.  PVC’s continued during the post exercise period with occasional PAC’s, again without repetitive forms.    Beginning at HR of 117 bpm, EKG changes began to develop with ST depression reaching 3 mm in the inferior leads at the end of the test.                                                                              HR                   BP Rest:                                                                      76                     142/78 ECG changes (5 mins, Stage 2):                          117                   180/80 Peak (6 mins, Stage 2):                                         130                   180/88   Pt completed 6 minutes (~7 METS), stopping because of developing substernal chest pressure and fullness in throat (anginal equivalent similar to MI presentation). He was given nitroglycerin and his chest pressure and full throat disappeared.  Limited cardiac exam post test was unremarkable. Echocardiogram (performed during admission) The left ventricle is normal in size.  Concentric remodeling (increased relative wall thickness and normal LV mass index).  Ejection Fraction = 40-45%;  Inferior Hypokinesis. No diastolic dysfunction parameters to suggest elevated left atrial pressure or congestive heart failure.  right ventricular systolic function is normal. No significant valvular disease. Tests and Measures: Resting Vitals: HR 72, RR 20, BP 146/76, RA SpO2 97%   Practical Examination: Patient is arriving at Phase 2 Outpatient Cardiac Rehabilitation, this is his first session, proceed with your evaluation/assessment/interventions/education. I have read the above case and am prepared for the practical exam:       

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