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

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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 29sec Status: Submitted Case Section Status Your Score Time spent Performance Details History Done 63% 12hr 5m i n 12sec correct, 13 missed relative (^60) questions asked,22 to the case's list Physical exams Done 83% 13hr 52mi n 55se c 53 exams performed, partially correct, case's list

correc t, missed relative

0 to the Key findin gs organization Done 34min 40sec 14 findings listed; 16 listed by the case Problem stateme nt Done 1hr 9m i n 29sec 150 words long; the case's was 117 words Differentials Done 88% 13min 14sec (^13) items misse d in relativ e DDx, 7 the case's list correct, 1 the to

Differenti als ranking Done 88% (lead/a lt score) 88% (must not miss score) 7mi n 38se c Tests Done 89% 50min 23sec 10 tests relativ e ordere d, to

the correct, 1 case'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% (of scored items only) 32mi n 51se c 3 of 5 correct 1 partially correct (of scored items only) 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 from further questioning.
2. Characterize the attributes of each symptom using details in the appropriate column "OLDCARTS". Capture the and row.
3. Review your findings and consider possible diagnoses that may correlate with these symptoms.(Remember to consider the patient's age and ris k factors.) Use you r ideas to help guide your physical examinati on the case. in the next section of HPI Sx = chest pain Sx = Sx = Sx = Sx = Sx = Onset 2.5^ hours^ ago Location deep in chest, pierces

Duration Characteristics worsens^ with^ deep^ inspiration Aggravating worsens^ when^ laying down, moving, and breathing Relieving eased pain when leaning forward Timing / Treatments Severity 8/ History of Present Illness Category Data^ entered^ by^ AA Reason for Encounter Chest pain Histor y of presen t illness 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 partiall y relieved by sitting up and leaning forward. She report s mild nausea without vomiting, denies fever/chills, palpitations, lightheadedness/syncop e, SOB, cough, URI, or extremity/catheterization site pain or swelling. She reports compliance with her antiplatelet medications (ASA

and clopidogrel), pantoprazole, and aspirin since

Mothe r

• Type 2 Diabetes

Sister - Type 2 Diabetes Social History Category Data^ entere^ 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.

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 with Snellen pocket card: OD 20/20, OS 20/20. Throat/Neck: Mucous membranes moist. Oropharynx without erythema, edema, or exudate. No stridor, no foreign body. No visible scars, deformities, or other lesions onneck inspection. Trachea is midline and freely mobile. JVP WNL Cardiovascular PMI nondisplaced. JVP WNL. No significant change while standing, squatting, duringValsalva maneuver or with sustained 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 vertebral body 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 pelvic exam. No masses or tenderness. Normal external genitalia. 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.

*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 limb oedema.

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 chest movements 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 sides and 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.