SCENARIO FOR CARDIOVASCULAR SYSTEM (Central) 2020
James Connery is 58 years old, and is a manager for an IT firm. He is extremely good at his job, and has made great progress in the last 5 years by climbing the ‘corporate ladder’ at a rapid speed. He was a gifted student with ability for creative, original thought. However, he has a strong work ethic of “you have to work hard to be successful” and quickly realised that the only way to get promotion was to go onto a management programme. His job is very stressful in terms of meeting deadlines, problem solving and decision making.
He works long hours, at times up to 14 hours a day, and frequently takes work home to complete or “think about”, even at the weekends. As a consequence of his work commitments he doesn’t find the time to socialise and unwind, the demands on his time prevent him from maintaining contact with his friends or even his teenage children. He says that he has no time for keeping in contact with friends, but recognises that this is making him feel isolated – a feeling that he also experiences at work as a consequence of “being management”. He has always believed he had a good relationship with his wife, Ursula, although she tends to “nag” out of concern about his lifestyle. He tends to argue with the children even when something is not really their own fault. Ursula has started visiting friends on her own and pursuing hobbies as she cannot rely on James to accompany her. She often goes to bed several hours before him because he is finishing his work. James sleeps 4 hours per night, partly because he goes to bed late but also wakes early with “things running through his head”. They have a comfortable lifestyle, but unfortunately very little time to enjoy the rewards that his hard work brings. There is a large house to maintain with an accompanying mortgage.
There is little time for exercise and lately and James has been experiencing repeated shoulder pain, especially when he has done DIY at the weekend. His GP has prescribed Ibuprofen, but didn’t do an ECG or refer him to the practice nurse.
James enjoys an after work drink of scotch and then red wine with dinner as he feels that it helps him to unwind. He eats a well-balanced diet at home, but tends to skip lunch at work and when away on frequent business trips indulges in high fat, high calorie meals – although this switching between diets does not seem to affect James’s bowel movements as he opens his bowels once a day – usually soft formed stool. His diet has however led to a rising BMI – currently James is 1.8 metres tall and weighs 16 stone, so his BMI is 32. He has tried to give up smoking 3 times in the last year but has found that the amount he smokes has increased to 30 per day as he uses it to deal with the stress that he feels. When he was younger, James and his wife had made plans to retire at 55 to the south of France and run a trout farm. However, the pressures of mortgages, and the introduction of university fees will mean that he will now need to work until he is 70, a thought that fills James with dread.
Earlier in the day of admission, James was carrying out some DIY when he felt a severe crushing pain in his chest, and collapsed on the floor. His colour was pale/grey and he was sweating profusely. His wife found him, and called 999 –the paramedic crew attended quickly and took James to the local A&E. On arrival, his pulse was 120 beats per minute and BP was 90/50. An ECG indicated an acute anterior Myocardial Infarction (MI). James was given Diamorphine 5mg and Metoclopramide 10mg as an anti-emetic – intravenously (IV). James was taken immediately to the cardiac catheter laboratory, where he underwent primary percutaneous coronary intervention (PCI) to “open up” the blocked coronary artery that was responsible for the MI.
Following the PCI, James was transferred to the Coronary Care Unit (CCU), where he stayed for the first part of his recovery – initially on bedrest for 24 hours. After admission repeat ECGs showed some evidence of reperfusion. Following admission to CCU, James remained pain free for 48 hours, and his condition has stabilised. MI has been confirmed through a rise in cardiac enzymes (specific substances that are usually released into the bloodstream only when the heart is damaged). Total cholesterol has been checked and found to be 6.4mmol/l.
James has now been transferred a step-down cardiology ward. His condition is currently stable with no chest pain – Heart rate 75/min, sinus rhythm, BP 110/60, oxygen saturation levels 99% on air, respiration rate 14/min, temp 36.8C – no bleeding is noted at the PCI site, from gums and nose and no headaches have been reported by James– his Hb is 14g/dl. James however remains very frightened about the pain returning and is reluctant to mobilise for this reason (Confidence level is 4 at best and 2 at worst on a scale of 1-10)– currently James is mobilising gently around the bed area and is able to wash his own hands, face and upper body. There is no swelling, redness, or heat apparent in James’s calves. James reports he is currently managing only 2 hours of disturbed sleep per night. He has no knowledge about heart problems or the care that he may need following an MI and fears that he will not be able to return to his previous health state (worry score is 8 at worst and 4 at best on a scale of 1-10). James is currently using a urinal to pass urine – his urine output is satisfactory and there is no blood in his urine, but he is experiencing some problems “going to the toilet” and has not had his bowels opened for 2 days – mainly because he is frightened of straining when opening his bowels in case he gets chest pain. James is also worried about the impact of his condition on his relationship with his wife.