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NUR631L Case Study 1 Patient: Shirley Time: 07/04/2024 Source and Reliability: Self-referred, reliable CC: “I have been having chest pain for the last four day

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NUR631L Case Study 1

Patient: Shirley

Time: 07/04/2024

Source and Reliability: Self-referred, reliable

CC: “I have been having chest pain for the last four days.”

HPI: Summary of what patient came to see you for based on scenario provided

Shirley is a 76yo female who presented to the clinic with complains of chest pain that has lasted about four days. She noted that she has been experiencing chest pain occasionally. However, four days ago, she noticed that the pain increased when she was engaged in activities such as her morning walk or walking the stairs and decreased when she rested. The chest pain radiates to her left shoulder and breasts. She also noted that he experiences tingling in her left arm.

PMH:

  • Childhood illnesses/conditions: No childhood illness.
  • Medical Conditions: HTN, HLD, CAD, DM, COPD, Hypothyroid
  • Surgical Hx: CABGX2 (2016)

Current medications:

  • Lisinopril 10mg Once daily
  • Amlodipine 5mg Daily
  • Lipitor 40mg once daily,
  • Pepcid 40mg BID
  • Ventolin Inh. PRN Q6hours
  • Metformin 1000mg BID
  • Synthroid 125mcg daily

Allergies: No allergies  

Psychosocial: She is married to her husband of 69 yo. She has three children, two daughters, one is 35 years old and the other is 34 years old and a son aged 38yo. She used to smoke1PPD of cigarettes. However, she quit 30 years ago. She takes 6-7 vodka seltzers/week. She often goes for a morning walk to take coffee with her girlfriends.

Family History – genogram

ROS

  • General: She denies chills, fever, nausea, or fatigue.
  • Skin: She denies rashes or itching
  • Head, Eyes, Ears, Nose, Throat (HEENT): Head: She denies lightheadedness, headache, or dizziness. Eyes: She denies use of glasses, vision problems, or pain in the eyes. No double vision. Ears: She denies earaches, discharge, infections, vertigo, or hearing problems. Nose and sinuses: She deny nasal stuffiness, frequent colds, hay fever, discharge, or sinus trouble. Throat (or mouth and pharynx): She denies bleeding gums, hoarseness, sore tongue, sore throats, or dry mouth.
  • Neck: She denies stiffness or pain in the neck or swollen glands.
  • Breasts: She denies nipple discharge.
  • Respiratory: She denies cough, shortness of breath, pleuritic pain, or wheezing.
  • Cardiovascular: Reports chest pain for four days. She denies edema.
  • Gastrointestinal: Denies nausea, diarrhea, heartburn, or trouble swallowing. No abdominal pain.
  • Peripheral Vascular: Denies varicose veins, leg cramps, or swelling in calves.
  • Urinary: She denies nighttime urination, UTIs, hematuria, or flank or kidney pain.
  • Genital: She denies menstruation.
  • Musculoskeletal: Denies muscle or joint pain or stiffness. Denies history of trauma.
  • Psychiatric: No depression, suicidal plans, or changes in mood.
  • Neurologic: She denies speech problem or memory problems. She reports tingling of the left arm.
  • Hematologic: She denies bleeding.
  • Endocrine: She denies endocrine problems.

Physical Exam – complete information

  • General: The patient is an average woman, aged 76 yo. She responds too questions well and is well-groomed. She is oriented to place, time, and people. She does not look distressed.
  • Vitals Signs: Temp 98.8 oral, HR 98, BP 168/76, RR 20, SPO2 90% RA HT:5’7”, WT: 185lbs
  • Skin: Fair with no rashes.
  • Head, Eyes, Ears, Nose, Thoat (HEENT): Head: Hair has good texture. NC/AT. Scalp without lesions. Eyes: No glasses. EOMI, PERRLA 2+ BL. Vision 20/20 in each eye. Sclera white, conjunctiva pink. Ears: Hearing is intact. Nose: Sinus not tender, mucosa pink, and septum midline. Mouth: Poor dental health with numerous plaque and dental caries sites. Oral mucosa pink, moist, intact. Tonsils 2+.
  • Neck: Neck supple. No palpable thyroid
  • Thorax and lungs: Thorax has good excursion and symmetric. No wheezes. Lungs with BL posterior lung wheezes/rhonchi that clear with coughing
  • Cardiovascular: S1 and S2 is normal. BP is high. No murmurs. Chest wall without pain to palpation, no rashes/lesions noted.
  • Breasts: No masses. No discharge.
  • Abdomen: Active bowel sounds. Abdomen flat. No masses or tenderness present.
  • Genitalia: No JVD or cervical lymphadenopathy.
  • Rectal: External hemorrhoids not present.
  • Extremities: Edema not present and warm. Nontender.
  • Peripheral vascular: Lower extremities as no varicosities.
  • Musculoskeletal: No swelling or inflammation in the muscles. Range of motion is good.
  • Neurologic: Cooperative and alert. Is oriented. Gait fluid and normal.
  • Sensory: Reflexes: 2+ at triceps, biceps, brachioradialis, achilles tendons, or patellar.

Diagnostic Testing:

  • CMP: BUN 30, CREA 1.0, Na 137, K 3.6, Glucose 118, BNP 90
  • CBC: Hgb 12.5, Plts 250
  • Chest X-Ray: No infiltrates, Heart size normal, No Rib Fractures
  • EKG Normal Sinus with PVC

2). Differential Diagnoses

  • Acute Coronary Syndrome (ACS)
  • Pulmonary Embolism (PE)
  • Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

3). The Pertinent Positives/Negatives to Support the Differentials (3positive/3negative):

Acute Coronary Syndrome (ACS)

Positives

  1. Chest pain for the last four days.
  2. Chest pain spreads to the patient’s left shoulder and in some instances to the left breast.
  3. Symptoms of chest pain start when she exercises or walks up the stairs, but stops at rest.

Negatives

  1. Denies chills, fever, or nausea.
  2. Denies diarrhea or vomiting
  3. Denies shortness of breath.

Pulmonary Embolism (PE)

Positives

  1. Positive for rapid breathing.
  2. Her BNP level is raised.
  3. She has risk factors for PE such as CAD, HTN, and COPD.

Negatives

  1. No coughs or shortness of breath.
  2. The patient’s lungs are normal with no abnormalities
  3. X-ray results show that the chest is normal

Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

Positives

  1. Positive for chest discomfort.
  2. History of COPD.
  3. Positive for rhonchi or wheezes.

Negatives

  1. No shortness of breath.
  2. Negative for fever.
  3. Negative for cough.

4). Additional History Data to Support the Primary Differential Diagnosis

  1. The patient’s family history of heart problems can be used to confirm the diagnosis. Bergmark et al. (2022) noted that individuals whose families have history of heart problems risk developing the disease. Therefore, I would ask the patient if there is any of her immediate family member with heart problems or died of heart disease.
  2. The second question will revolve around the patient’s past medical history. I will ask her if he has ever suffered stroke or heart attacks before (Bergmark et al., 2022). Previous history of heart attacks or stroke increases one’s chances of developing ACS.
  3. I will also ask the patient if she has diabetes. Diabetes is also a risk factor of ACS.
  4. Asking the patient if she was infected with covid-19 virus is also vital because it also increases the patient’s chances of developing ACS (Bergmark et al., 2022).
  5. Lastly, I would assess the patient’s compliance to past treatments. Information about how she complied with her past medication instructions is vital in determining the current diagnosis (Bergmark et al., 2022). If she did not comply with her past heart disease medications, she would be at risk of developing ACS.

5). Additional Physical Components

  • Physical exam should include assessment of neck, stomach, back, the jaw, and both arms to determine whether the patient experiences discomfort or pain in these areas. ACS often cause discomfort and pain in muscles around the neck, stomach, back, the jaw, and both arms (Bergmark et al., 2022).
  • The patient’s blood pressure should also be measured to determine whether the patient experiences pulsus Low blood pressure is a sign of various heart problems including ACS (Bergmark et al., 2022).
  • Physical exams to assess for heart murmurs should also be conducted. ACS also causes a new mitral regurgitation murmur. This physical exam can be used to confirm ACS diagnosis.
  • Physical exam can also be done to assess for pulmonary rales. These sounds occur when a patient breaths in. Further exam can be done to assess the characteristics of the sounds (Bergmark et al., 2022).
  • Physical exam can also involve assessment for new jugular venous distention. The abnormality can indicate problem in the patient’s heart that causes the chest pain.

6). Primary Differential Diagnosis:

Acute Coronary Syndrome (ACS)

The primary diagnosis for this case is ACS. It is a heart condition that occurs when blood flow to the heart is reduced. Its symptoms include sweating, feeling lightheaded or dizzy, nausea, shortness of breath, feeling discomfort or pain in the back, jaw, neck, stomach, or both arms, and chest pain that might be characterized with fullness, tightness, or pressure (Theofilis et al., 2023).

ACS is the main diagnosis based on a lot of information provided by the patient. She noted that he experiences chest pain that radiates to the left shoulder and best breast. The pain increases when she engages in physical activities but reduces when she rests. The pain is also accompanied with occasional tingling in her left arm. The patient’s medical history and age also puts her at risk of developing ACS. Has history of smoking cigarettes, COPD, CAD, HTN, and is advanced in age. These factors increase her chances of developing ACS (Theofilis et al., 2023).

Pathophysiology of Differential Diagnoses

ACS

ACS is primarily caused by a decrease in blood supply to a part of the cardiac muscle (Theofilis et al., 2023). Theofilis et al. (2023) noted that this is the basic pathway of ACS and is usually caused by plaque rupture or thrombus formation. The underlying vasospasm causing ACS may or may not have atherosclerosis. A decrease in blood flow to a section of the heart’s muscle causes first ischemia and then infarction (Theofilis et al., 2023).

Pulmonary Embolism

PE is a condition in which a blood clot (or any clot-like material) gets stuck in an artery in the lung, preventing blood from flowing and exiting the lungs (Duffett et al., 2020). According to, clots may move through the circulatory system and the heart’s right side to lodge in pulmonary arteries. These clots may partially or completely block one or more blood vessels once deep vein thromboses (DVT) occur (Duffett et al., 2020).

Factors such as the size and number of emboli in the lungs, the underlying health of the lungs, the effectiveness of right ventricular (RV) function, and the body’s internal thrombolytic system’s ability to break down the clot all play a role in the outcome of PE (Duffett et al., 2020). Right ventricular failure (LVF) is often the cause of death.

Chronic Obstructive Pulmonary Disease

COPD’s pathophysiological hallmark is expiratory flow limitation (EFL). When a COPD patient generates the maximal amount of EFL through tidal breathing, they are considered to be flow limited at this volume (Ritchie & Wedzicha, 2020). In patients with blood flow restriction, there is often insufficient time for EELV to return to its natural volume of relaxation during spontaneous breathing.

This can lead to pulmonary overinflation, resulting in EELV being dynamically determined (i.e., not statically determined) (Ritchie & Wedzicha, 2020). Dynamic hyperinflation (DH) is an abrupt and variable increase in EELV over its baseline value. Dynamic hyperinflation is a condition in which EELV rises and falls rapidly in response to mechanical ventilation restrictions, resulting in subjective respiratory discomfort (Ritchie & Wedzicha, 2020).

Etiology

ACS

Bergmark et al. (2022) noted that ACS is an indication that one has coronary heart disease. It is caused by atherosclerosis, a plaque disruption in the coronary arteries. The risk factors of the disease include male sex, hyperlipemia, diabetes, high blood pressure, family history of obesity, sedentary life, smoking, and poor eating habits (Bergmark et al., 2022). Those taking cocaine are also at risk of developing the disease. Another high-risk factor is early myocardial infarction.

PE

In most cases, PE occurs because of presence of thrombi in the pelvis or legs veins. It can also be caused by non-thrombotic sources such as fat, foreign body, infected material, amniotic fluid, and tumor (Duffett et al., 2020). It can also occur due to air bubbles. Other predisposing factors include obesity, infection, hormone therapy replacement, central venous lines pregnancy, bed rest for more than three days, history of previous venous thromboembolism, and knee or hip replacement. Overall, Duffett et al. (2020) the primary cause is blood clot in the veins supplying blood to the lungs leading to low supply of blood in the lungs.

COPD

COPD is caused by many factors. One of the factors is smoking cigarettes. Ritchie and Wedzicha (2020) noted that cigarettes are the biggest caused of COPD. Another cause is being exposed to toxic gasses and harmful substances. Other causes include alpha-1 antitrypsin deficiency (AATD), environmental and occupational exposures, and second-hand smoke (Ritchie & Wedzicha, 2020).

Usual clinical findings associated with primary DD

One of the usual findings related to ACS is chest discomfort or pain. People with ACS often experience chest pain that can radiate to other parts of the body such as shoulders, breast, and arms (Bergmark et al., 2022). A patient might describe the chest pain as burning, tightness, pressure, or aching. Another usual clinical finding is shortness of breath. Patients with ACS commonly experience breathing problems due to poor blood floor.

Bergmark et al. (2022) reported that patients with ACS might also show at the clinic sweating profoundly and sudden. Their heartbeat might also be racing. Ingestion is another common clinical sign of ACS. Other common clinical manifestations include unusual fatigue, feeling dizzy or lightheaded, and fainting (Bergmark et al., 2022). The patient might also come to the clinic feeling worried or anxious.

Diagnostic criteria

Diagnosing ACS is done in many phases. The first step is to assess the patient by collecting her medication history (Luciano et al., 2019). Medical history can tell whether the patient is at risk of suffering ACS. The clinical symptoms the patient presents with should also be used to inform diagnosis decision. After taking data on the patient’s past medical history and present symptoms, lab tests and imaging should be ordered (Luciano et al., 2019).

Blood test should be ordered to check for heart proteins that have leaked into the blood due to heart damage. EKG can be done to measure the electrical activity of the patient’s heart (Luciano et al., 2019). The test can be used to identify the location of the blockage. Coronary angiogram can also be ordered to identify the exact location of the heart arteries blockage.

Treatment Plan

Aspirin (300 mg), heparin bolus, and intravenous (IV) heparin infusion are the first treatments for all ACS, provided there are no contraindications (Gilutz et al., 2019). It is also advised to use ticagrelor or clopidogrel for antiplatelet treatment. Selection is based on the preferences of the local cardiologist. Patients undergoing thrombolysis do not receive ticagrelor.

When necessary, supportive measures are given, such as oxygen in the event of hypoxia and pain management with morphine or fentanyl (Gilutz et al., 2019). For pain treatment, nitroglycerin sublingual or infusion is also an option. Nitroglycerine can result in severe hypotension in cases with inferior wall ischemia, hence it should be taken very sparingly, if at all. It is necessary to monitor the heart continuously for arrhythmias (Gilutz et al., 2019).