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Case Study: Intermittent Squeezing Chest Pain in a 49-Year-Old Patient - Prof. Weatherford, Exams of Nursing

This case study presents a detailed analysis of a 49-year-old female patient experiencing intermittent squeezing chest pain. A comprehensive history, physical exam findings, and a detailed analysis of the patient's condition. It provides insights into the diagnostic process, differential diagnoses, and management strategies for chest pain. The case study also includes exercises and questions to test understanding and critical thinking skills.

Typology: Exams

2024/2025

Available from 12/06/2024

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Download Case Study: Intermittent Squeezing Chest Pain in a 49-Year-Old Patient - Prof. Weatherford and more Exams Nursing in PDF only on Docsity!

I HUMAN CASE STUDY (WEEK 7) FOR A 49 -

YEAR-OLD PATIENT REASON FOR

ENCOUNTER; INTERMITTENT SQUEEZING

CHEST PAIN|| ACTUAL COMPREHENSIVE

CASE STUDY (RESEARCH ANALYSIS AND

RESULTS) LATEST AND COMPLETE VERSION

2024 - 2025 ALREADY GRADED A+||

The following table summarizes your performance on each

section of the case, whether you completed that section or not.

Time spent: 1dy 13hr 58min

29secStatus: Submitted

Case Section Status

Your

Score

Time spent

Performance Details

History Done 63% 12hr

5m

in 12sec

questions asked,22 to

the case's list

correct, 13 missed

relative

Physical exams Done 83%

13hr

53 exams

performed, 0

partially correct,

case's list

correc to the

t, missed

relative

52mi

n

55se

c

Key

findin

gs organization

Done

34min

40sec

14 findings listed; 16 listed by the case

Problem

Done 1hr

9m

in 29sec

150 words long; the case's was 117 words

stateme

nt

Differentials Done 88%

13min

14sec

items in

the to

misse relativ

d e

DDx, 7

correct, 1

the case's list

AA

History Notecard by AA on case

Use this worksheet to organize your thoughts before developing a differential diagnosis list.

  1. Indicate key symptoms ( Sx ) you have identified from the history. Start with the

patient's reason(s) for the encounter and add additional symptoms obtained

fromfurther questioning.

  1. Characterize the attributes of each symptom using details in the appropriate

column "OLDCARTS". Capture

theand row.

  1. Review your findings and consider possible diagnoses that may correlate with these

symptoms.(Remember to consider the patient's age and ris factors.) Use

k you

r

ideas to help guide your examinati the case. in the next section of

physical on

HPI Sx = chest pain

Sx

=

Sx

=

Sx

=

Sx

=

Sx

=

Onset

2.5 hours ago

Location deep in chest, pierces

Differenti

als

ranking

Done 88%

(lead/a

lt

score)

88%

(must

not

miss

score)

7mi

n

38se

c

Tests Done 89%

50min

23sec

tests

relativ

e

ordere

d, to

the

correct,

1case's

list

missed

Diagnosis Done 100% 21sec

Manageme

nt plan

Done

46min 0sec

1645 words long; the case's was 79 words

Exercises Done

68%

32mi

n

51se

c

3 of 5

correct

partially correct

(of scored items only)

(of

scored

items

only)

through back

History of Present Illness

Category

Data entered by AA

Reason for Encounter Chest pain

Histor of presen illness

y t

A 57 - year-old female 10 days status post inferolateral

STEMI with stent placement, presents to the ED

with a 2.5-hour history of progressively worsening

chest pain. The pain is sharp and stabbing, gets

to pierce through her back with inspiration. Pain

is relieved by sitting up and leaning

partiall forward.

y

She mild nausea vomiting, denies

report without fever/chills,

s

palpitations, lightheadedness/syncop SOB, cough, URI, or

e,

extremity/catheterization site or swelling. She reports

pain

compliance with her antiplatelet medications (ASA

Duration

Characteristics

worsens with deep inspiration

Aggravating

worsens when laying

down, moving, and

breathing

Relieving eased pain when leaning

forward

Timing /

Treatments

Severity 8/

and clopidogrel), pantoprazole, and aspirin since

discharge. On exam, patient is febrile, shallow

respirations at norma rate, low-normal oxygen

l

saturation, and has pericardial friction rub. PMH

is significant for hypertension, tobacco

hyperlipidemi

a,

abuse, obesity, and family history of heart attack and

type- 2 diabetes.

Past Medical History

Medications

Allergies

Preventive Health

Family History

Category

Data entered by AA

Family History Fathe - Heart attack, 59 years old

r

Category

Data entered by AA

Past Medical History Hypertension Hyperlipidemia

Hospitalizations / Surgeries Acute

Balloo

n

inferolateral

PCI/stenting

angioplasty

wall

of

of

ST-elevation

the righ

t

the left

myocardial

coronary

artery

circumflex

infarction with

(RCA).

artery.

Category

Data entered by A

A

Medications Clopidogrel

Atorvastatin

Pantoprazole

Aspirin 81

mg

mg

mg

mg

QD

QD

QD

QD

at bedtime

Category

Data entered by AA

Allergies Bactrim (rash)

Category

Data entered by AA

Preventive health Up to date immunizatio

n

annually. Reports

gynecologynormal.

including flu

exam was

shots

Mothe

r

  • Type 2 Diabetes

Sister - Type 2 Diabetes

Social History

Category

Data enter d by AA

Social History Freelance worker, telephone sales. Smoked a pack and a

half for the past 25

years

.

Quitte

d

since she’d

the heart

attac

k

and takes a

health

y

heart diet.

Review of Systems

Category

Data entered by AA

General

Slightl

y

fatigued. Laying still to avoid movement,

breathing slowly.

Integumentar

y

/ Breast Warm skin; no significant diaphoresis.

HEENT / Neck Denies any problems with headaches, double vision, difficulty with

night vision,

hearing

problems, ear pain, sinus

problems,

chron

ic

sore

throat

s,

or difficulty swallowing.

Cardiovascular Chest pain. Heart attack 10 days ago.

Denies history of irregular heartbeats

nor Hypertension

Hyperlipidemia

palpitations.

Respiratory Denies wheezing and

sputu

m

production.

Gastrointestinal

Report

s

mild nausea and reflux.

Genitourinary Denies urinary frequency, pain, incontinence, or difficulty.

Musculoskeletal Denies chest injury. No problems with

muscle

s

and joints.

Allergic / Immunologic

Endocrine Denies problems with heat or cold intolerance, increased thirst,

increased sweating, frequent urination,

or

change in appetite.

Hematologic /

Lympha

tic

No

reports of bruising, bleeding

gums, sites of increased

bleeding.

nose bleeds, or other

Neurologic Denies dizziness, seizures, numbness, or weakness.

Psychiatric

Report

s

nervousness due to chest pain.

Physical Exams

Data entered by AA

Category

General Obese with a BMI of 29.4.

AOx

Skin

is dry and febril

e.

Skin Skin warm and dry with no lesions.

Nails withou

t

ridgin

g,

pitting

,

or peeling.

Capillary refill < 2 sec.

Quincke’s

Test:

Blanching observed.

HEENT / Neck Head: Normocephalic, atraumatic, no deformities, facial

features symmetric.Temporal arteries non-tender

to palpation.

Frontal and maxillary sinuses non-tender.

Eyes: Normal conjunctivae on inspection. Visual acuity

withSnellen pocket card: OD 20/20, OS

20/20.

Throat/Neck: Mucous membranes moist. Oropharynx without

erythema, edema, or exudate. No

stridor, no foreignbody. No visible scars,

deformities, or other lesionsonneck inspection.

Trachea is midline and freely

mobile. JVP

WNL

Cardiovascular PMI nondisplaced. JVP WNL. No significant change while

standing, squatting, duringValsalva maneuver or

withsustained handgrip.

Chest / Respiratory Thorax atraumatic; no postsurgical scars. Respirations

shallow, normal rate, nonlabored. No

visible bounding of the

chest. No tenderness to chest wall or

vertebralbody palpation. No palpable thrill.

Normal tactile fremitus.

Thorax normal/symmetrical to percussion.

Normal lungs sounds bilaterally.

Abdomen Abdomen atraumatic, obese, nondistended. Normoactive bowel sounds.

No hepatosplenomegaly or palpable masses.

Soft, nontender throughout exam.

Genitourinary / Rectal Normal pelvicexam. No masses or tenderness. Normal

externalgenitalia.

Musculoskeletal /

Osteopathic

Structural

Examination

Normal muscle bulk. No evidence of swelling. calf tenderness or

No inflammatory peripheral edema.

signs.

No

No asymmetry or deformity of the back. No

tenderness or spasm of the paraspinal

muscles.

No localized tenderness of the spinous

processes or pelvic structures.

Neurologic PERRLA.CN II-XII intact.

Psychiatric AOx

Lymphatic No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary

or inguinal chains.

*History of present illness

Patient known to be ischemic heart. Recently he developed retrosternal burning and compressing chest pain, with acute

onset intermittent course for 5 hours. Not radiating , notrelieved by sublingual nitrates , not associated with dyspnea.

there is no history of syncope, palpitation, bluish discoloration of peripheries or lower limboedema.

The pain is not aggravated by chest movement and not relieved by changing posture.

There is no cough, haemoptysis, or audible breathing sounds.

There is no history of dysphagia, odynophagia, hematemesis or heartburn .There is no history of

chest trauma.

There were no symptoms suggesting other systems affection.

*Past History

Patient has history of PCI since 2 years. The patient condition started 3 years ago when he had similar attacks of chest

pain that occurred repeatedly despite receiving sublingual Nitroglycerine tablets. There are no other chronic diseases,

no drug allergy, no history of operations and no blood transfusion

*Family History

There are no chronic disease running in family or similar attacks. Emergency Department

Examination

1ry Survey:

Airway:

The patient has patent airways Breathing:

By Inspection, the Respiratory Rate is 14 breathes / minute, there is symmetrical chestmovements and there is

no chest deformity.

By Palpation, There is no chest tenderness, there is symmetrical chest expansion & there isno shifting of trachea.

By Percussion, No Hyper-resonance

By Auscultation, No Abnormal Breathing sounds.

Circulation:

Central Pulsation is felt, central to peripheral pulsation is comparable &

peripheraltoperipheral pulsation is also comparable.

Radial pulsation is 63 beats per min, regular, of average volume, symmetrical in both sidesand has no special

characters.

Blood Pressure: 115 / 85 mmHg (Normal) Capillary Filling time: less than 2 seconds.

Disability:

The Patient is Alert on AVPU Score.

The pupils are rounded, central, responsive to light & equal on both sides. Exposure:

No apparent injuries in body.

General Examination

Patient is alert , conscious , oriented to time , place and persons , average built , quiet facial expression , no special

decubitus , average intelligence ,he's cooperative

Cardiac Examination

By

inspection:

There is no skin redness, pigmentation, ulceration, fistulae or scars.Respiration is

abdomenothoracic.

No visible pulsation at the apex of the heart.

By Palpation:

Palpable pulsation of the heart at the fifth intercostal space in the midclavicular line.There are no masses,

swellings, tenderness or pulsating masses.

By Auscultation:

No abnormal cardiac sounds, muffling or murmurs were heard at the apex of the heart,xiphisternal area and

aortic areas.

Differential Diagnosis

1. Acute Coronary Syndrome (most probable)

2. Pericarditis excluded by absence of localized friction rub over pericardium.

3. Aortic Dissection excluded by absence of unequal pulsation or pulsating masses.

4. Musculoskeletal Pain excluded by not being aggravated by chest movement and notbeing relieved by

changing posture.

5. Pleurisy, Bronchitis, Broncho-Pneumonia or Lung Carcinoma excluded by absence of cough, haemoptysis,

friction rub on the chest and audible abnormal breathing sounds.

6. Esophagitis or peptic ulcer excluded by absence of history of dysphagia, odynophagia,hematemesis or

heartburn.

Provisional Diagnosis

A 58 years old male ischemic patient came complaining of intermittent retrosternal sever chest

tightness, with no radiation for 5 hours duration most probably caused by UnStable AnginaPectoris not complicated.

Management

The patient should be admitted and have the following investigations:

1. 12 Leads ECG for any abnormal findings including T-wave inversion or ST segment elevation.

2. Cardiac enzymes (Myoglobin, Troponin I and CK MB.)

3. Chest X ray (for exclusion of trauma, pulmonary conditions & aortic aneurysm).

The patient should receive:

1. Aspirin 300 mg for chewing (to prevent propagation of the thrombus)

2. Oxygen inhalation session (5- 10 Litres / minute)

3. Nitro glycerine 10 mg sublingual tablets (for coronary vasodilatation) >> ask 1

st

about intake of

sildenafil.

4. Morphine 5 - 10 mg IV (for relieving pain)

If the patient’s condition improved he should be put under observation for 24 hours.

Drugs taken after stabilization of the condition:

5. Heparin SC injection (to prevent new thrombus formation)

6. Glycoprotein IIb & IIIa inhibitors.

7. Beta Blockers to decrease cardiac demands

8. Diltiazim (if beta blockers are contraindicated, e.g. Asthma) If the patient’s condition didn’t improve orMI was

present

9. Primary PCI within 90 minutes (if available)

10. Thrombolytics if PCI is not available (unless absolutely Contraindicated)

Scientific background

Chest pain

INTRODUCTION

Patients with acute no traumatic chest pain are among the most challenging patients cared for by emergency physicians.

They may appear seriously ill or completely well and yet remain at significant risk for sudden death or an acute

myocardial infarction (AMI).

CLINICAL FEATURES

The typical pain of myocardial ischemia has been described as retrosternal or epigastric squeezing, tightening, crushing,