1. Discuss the significance of left main coronary artery stenosis.

Left main coronary artery is the artery from the point of origin to the first major branch. There is also two branches arise from Left main coronary artery: the left anterior descending artery which courses down the anterior wall of the heart, and the circumflex artery , which circles around to the lateral left wall of the heart. In LMCA stenosis, what happens is that there is a narrowing of the blood vessel resulting to decreased blood supply to the heart and a decreased cardiac output of the heart. Whenever there is a decreased CO there would also be less blood circulating in the system. Which may cause decreased in urine output, weak and often irregular pulse, changes in cellular structure that may cause changes in the LOC. 2. Explain the rationale of Mr. Romulos urinary output values. Mr. Romulos urine output decreases because the bypass that serves as another route for the blood to flow and supplies blood to the heart and circulation was terminated. Meaning, there is still stenosis on mr.romulos heart. This happens because of a decrease perfusion on the kidney. And this could also be a compensatory mechanism of our body that reserves the available fluid. 3. Discuss 4 postoperative exercises that a patient should perform to prevent postoperative complications. a. Deep breathing exercise improves lung function and helps clear secretions as we exhale. b. Splinting and coughing c. Leg exercise prevents DVT by promoting circulation and compressing of the muscle that can pump the blood back to the circulation d. Range of motion exercise prevent muscle atrophy and improves circulation. 4. Discuss the mode of action of all the drugs mentioned in the situation. DRUG ACTION 1. Amlodipine besilate + Valsartan is a type of medicine called an valsartan (exforge) 1 tab angiotensin II receptor antagonist. Amlodipine is a HS. type of medicine called a calcium-channel blocker. These are both medicines used to lower high blood pressure. Valsartan works by preventing the action of a hormone in the body called angiotensin II. Angiotensin II normally acts on special receptors

2. Enalapril Maleate (hypace) 1 tab OD

in the body, with two main results. It causes the peripheral blood vessels to narrow, and it also stimulates the production of another hormone called aldosterone. Aldosterone causes salt and water to be retained by the kidneys, which increases the volume of fluid in the blood vessels. Valsartan blocks the receptors that angiotensin II acts on and so prevents its actions. The main result of this is that the peripheral blood vessels are allowed to widen, which means that there is more space and less resistance in these blood vessels. This helps lower blood pressure. Enalapril is used to treat high blood pressure (hypertension ). Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. It is also used to treat heart failure. Enalapril is an ACE inhibitor and works by relaxing blood vessels so that blood can flow more easily. Aspirin belongs to a group of medicines called non-steroidal anti-inflammatory drugs (NSAIDs). It works by blocking the action of a substance in the body called cyclo-oxygenase. Cyclo-oxygenase is involved in the production of various chemicals in the body. These are known as prostaglandins, prostacyclins and thromboxane. By blocking the action of cylo-oxygenase, aspirin prevents the production of these chemicals. Low doses of aspirin prevent the production of thromboxane by blood cells called platelets. Thromboxane is one of the chemicals that cause platelets to clump together and start off the clotting process. Stopping its production therefore reduces the likelihood of clots forming in the blood. Clots in the blood can cause a heart attack or stroke, and low dose aspirin is therefore used to prevent this in people who are at risk. Cordarone X tablets contain the active ingredient amiodarone, which is a type of medicine called an

3. Aspirin 80mg 1 tab OD

4. Amiodarone (cordarone) 1 tab OD

5. Dobutamine (Dobutrex)

6. Nitroglycerin

antiarrhythmic. Amiodarone is used to control abnormal heartbeats. The heart's pumping action is controlled by electrical signals that pass through the heart muscle. The electrical signals causes the two pairs of heart chambers (left and right atria and ventricles) to contract in a regular manner that produces the heartbeat. If the electrical activity in the heart is disturbed for any reason, irregular heartbeats (arrhythmias) of various types can result. These can seriously undermine the pumping action of the heart and result in inefficient blood circulation around the body. Dobutamine is a sympathomimetic drug used in the treatment of heart failure and cardiogenic shock. Its primary mechanism is direct stimulation of 1 receptors of the sympathetic nervous system. The effects of this drug include positive inotropic effects with minimal changes in chronotropic activities or systemic vascular resistance. For these reasons, dobutamine is useful in managing congestive heart failure when an increase in heart rate is not desired. Nitroglycerin has a dose-dependent vasodilator effect in arteries and veins and is active in the systemic and pulmonary circulations. When the drug is given by continuous infusion, venous dilator effects are prominent at low dose rates. As low-dose infusions are titrated upward, the earliest response is a decrease in cardiac filling pressures (i.e., central venous pressure and wedge pressure) with little or no change in cardiac output. As the dose rate is increased further, the cardiac output begins to rise as a result of progressive arterial vasodilation. Further increases in the dose rate will eventually produce a drop in blood pressure

5. Explain the purpose of the swan-ganz catheter in Mr. Romulo. What are the potential complications associated with its use? The purpose of Swan-Ganz or PAC (pulmonary artery catheterization) is the insertion of a catheter into a pulmonary artery. The pulmonary artery catheter allows direct, simultaneous measurement of pressures in the right atrium, right ventricle, pulmonary artery, and the filling pressure ("wedge" pressure) of the left atrium. Some of the potential complications with its use are; arrhythmias, rupture of the pulmonary artery, thrombosis, infection, pneumothorax and bleeding.

Hematologic study Haemoglobin (Hgb)

Actual finding 10.3 % g/dl

Normal finding 13-18 g/dl

Implications Transports oxygen to the cell. Low Hgb may indicate frequent angina episodes or MI Glucose level increases in stressful situation. When mobilization of endogenous epinephrine results in conversion of liver glycogen to glucose. Decreased potassium level may cause many forms of dysrhythmias including life threatening ventricular tachycardia, ventricular fibrillation. Absorption of calcium, maintenance of potassium stores and metabolism of ATP. Plays a major role in CHO, CHON synthesis and muscular contraction.

Hematocrit (Hct) Glucose

33% 250 mg/dl

42-52% 60-100 mg/dl

Potassium

3.2 mmo/L

3.5-5 mmo/l

Magnesium

1.5

1.3-2.3

ABG COMPONENT pH PO2 PCO2 HCO3 SaO2

Actual finding 7.3 156 mmHg 48 mmHg 16mmol/L 96%

Nomal Value 7.35-7.45 80-100 35-45 22-26 95-100%

Implication