FLORENCE BLACKMAN iHUMAN 49 YEARS OLD FEMALE PRESENTS WITH INTERMITTENT SQUEEZING CHEST, Exams of Nursing

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FLORENCE BLACKMAN iHUMAN 49 YEARS OLD FEMALE PRESENTS WITH INTERMITTENT SQUEEZING CHEST PAIN

FLORENCE BLACKMAN iHUMAN 49 YEARS OLD

FEMALE PRESENTS WITH INTERMITTENT

SQUEEZING CHEST PAIN

CHEST PAIN

The iHuman assignment for Week 7 of Walden University’s NURS 6512 typically involves a case study of a 49-year-old female patient, Florence Blackman, who presents with intermittent squeezing chest pain. This case requires you to assess the patient's symptoms, take a detailed history, perform a physical exam, and develop a differential diagnosis based on the findings. You will also create a management plan tailored to the patient's needs. This assignment emphasizes critical thinking in diagnosing and managing chest pain, which could potentially be related to cardiac issues or other differential diagnoses.

Be sure to focus on gathering the patient's history of present illness (HPI), including when the chest pain started, any triggers, and accompanying symptoms like shortness of breath or radiation of the pain. The physical exam will guide you in narrowing down the possible causes. The differential diagnosis might include conditions like angina, myocardial infarction, or gastrointestinal causes such as GERD.

• Consider what physical exams and diagnostic tests would be most appropriate to gather more information about the patient’s condition.
• Reflect on how the results would be used to make a diagnosis.
• Identify three to five (3–5) possible conditions that may be considered in a differential diagnosis for the patient.
• Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
• Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with cardiovascular conditions.

Physical Exams:

1. Cardiac Examination : o Inspection : Look for signs of cyanosis or pallor. o Palpation : Assess for tenderness (which might indicate musculoskeletal origin) and abnormal precordial movements. o Auscultation : Listen for abnormal heart sounds like murmurs, gallops (S3, S4), or rubs, which may indicate heart failure, ischemia, or pericarditis.
2. Respiratory Examination : o Auscultation : Listen for crackles, wheezes, or diminished breath sounds, which could indicate heart failure or a pulmonary condition like a pulmonary embolism.
3. Abdominal Exam : o Palpation : Rule out epigastric tenderness, which could suggest GERD or a peptic ulcer.
4. Musculoskeletal Exam : o Assess for tenderness along the chest wall to rule out costochondritis or musculoskeletal pain that might mimic cardiac issues.

CHEST PAIN

Immediate treatment, such as anticoagulation, antiplatelet therapy, or even percutaneous coronary intervention (PCI), would be necessary.

2. Cardiac Enzymes (Troponins) Results:

• Elevated Troponins : These indicate myocardial injury, typically due to MI. Elevated troponins would lead to the diagnosis of an acute coronary event and would prompt emergency management, such as coronary angiography and revascularization.
• Normal Troponins : This would reduce the likelihood of an MI but does not rule out other causes of chest pain, such as unstable angina or non-cardiac causes.

3. Chest X-ray Results:

• Normal X-ray : If the chest x-ray is normal, pulmonary causes of chest pain such as pneumothorax or pneumonia would be unlikely. However, it doesn’t rule out conditions like pulmonary embolism or aortic dissection, which may need further imaging (e.g., CT angiography).
• Abnormal X-ray : Findings such as an enlarged cardiac silhouette might suggest heart failure or pericardial effusion, while lung infiltrates or pleural effusion could point toward a pulmonary cause of the symptoms.

4. Echocardiogram Results:

• If Normal : A normal echocardiogram would indicate that the heart’s structure and function are intact. This would lower the likelihood of valvular heart disease, heart failure, or cardiomyopathy as causes of chest pain.
• If Abnormal : An echocardiogram showing wall motion abnormalities could confirm ischemic heart disease. Valvular abnormalities or signs of heart failure (e.g., reduced ejection fraction) would provide clues to the underlying diagnosis.

5. Stress Test Results:

• If Positive : A positive stress test, where the patient develops chest pain or ECG changes during exercise, would suggest ischemic heart disease. This would likely lead to further diagnostic testing such as coronary angiography.
• If Negative : A negative stress test would reduce the likelihood of coronary artery disease, shifting the focus to other non-cardiac causes of chest pain.

6. Endoscopy Results:

• If Positive : If endoscopy reveals esophagitis or a peptic ulcer, the diagnosis would lean toward a gastrointestinal cause, such as GERD or peptic ulcer disease.
• If Normal : This would rule out many GI causes of chest pain and redirect the diagnostic focus toward cardiac or musculoskeletal causes.

7. Blood Tests (CBC, Lipid Profile, BMP):

CHEST PAIN

• Abnormal CBC : Anemia (e.g., low hemoglobin) can exacerbate angina or ischemic symptoms due to reduced oxygen-carrying capacity. Addressing the anemia might help alleviate chest pain.
• Abnormal Lipid Profile : Elevated cholesterol levels (high LDL, low HDL) would suggest a risk for atherosclerosis and could help confirm a diagnosis of coronary artery disease if other findings also align.
• Abnormal Electrolytes or Renal Function : These would influence management, particularly in patients with cardiovascular risk factors, as electrolyte imbalances or renal dysfunction can complicate the management of chest pain or suggest other underlying conditions like heart failure.

Conclusion:

The combination of physical exam findings and diagnostic test results would guide the final diagnosis. If tests point toward ischemic heart disease (e.g., abnormal ECG, elevated troponins), the diagnosis would likely be myocardial infarction or unstable angina. If tests are more indicative of gastrointestinal issues (e.g., endoscopy findings), a diagnosis of GERD might be more appropriate. By systematically ruling out or confirming conditions, the healthcare provider can develop a targeted treatment plan based on the underlying cause of the chest pain.

For a 49-year-old female presenting with intermittent squeezing chest pain, several conditions could be considered in a differential diagnosis. Here are 3-5 possible diagnoses:

1. Stable or Unstable Angina:

• Stable Angina is characterized by predictable chest pain triggered by physical exertion or emotional stress and relieved by rest or nitroglycerin. It suggests underlying coronary artery disease (CAD), but no immediate risk of myocardial infarction (MI).
• Unstable Angina involves unpredictable or worsening chest pain that occurs at rest, indicating an increased risk of a heart attack. Both forms require prompt evaluation, as they suggest coronary ischemia.

Tests : ECG, cardiac enzymes, stress test, coronary angiography.

2. Myocardial Infarction (MI):

• An MI (heart attack) occurs when blood flow to the heart muscle is blocked, causing tissue damage. This is a life-threatening condition that often presents with squeezing or crushing chest pain, often radiating to the jaw or left arm, accompanied by nausea, diaphoresis (sweating), or dyspnea.

Tests : ECG showing ST-segment elevation, elevated cardiac enzymes (troponin), coronary angiography.

3. Gastroesophageal Reflux Disease (GERD):

CHEST PAIN

References : ACC/AHA 2021 Guidelines for the Management of Patients with Acute Coronary Syndromes.

2. Gastroesophageal Reflux Disease (GERD):

• Clinical Guideline : The American College of Gastroenterology (ACG) provides guidelines for managing GERD. Initial management involves lifestyle modifications (e.g., weight loss, avoiding trigger foods, elevating the head of the bed) and pharmacologic therapy with proton pump inhibitors (PPIs). For patients with persistent symptoms, an upper endoscopy is recommended to evaluate for complications such as esophagitis or Barrett’s esophagus.

References : ACG 2022 Guidelines for GERD Management.

3. Pulmonary Embolism (PE):

• Clinical Guideline : The European Society of Cardiology (ESC) guidelines emphasize prompt diagnosis using a combination of clinical prediction rules like the Wells score and diagnostic tests such as D-dimer assays and CT pulmonary angiography. High- risk patients with PE require immediate anticoagulation therapy, and thrombolysis may be considered in severe cases.

References : ESC Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism,

These guidelines help inform the diagnostic process and treatment plans by providing a structured approach to the evaluation of chest pain, ensuring that life-threatening conditions are identified early and managed effectively.

Developing a treatment plan for a patient with a cardiovascular condition, such as unstable angina or myocardial infarction , involves immediate medical intervention, long-term management, and promoting lifestyle changes to improve heart health and prevent future events.

1. Acute Management (If the diagnosis is Unstable Angina or MI):

• Medications : o Aspirin (Antiplatelet therapy) : A standard dose of 162-325 mg of aspirin should be given immediately, followed by a maintenance dose to prevent further clot formation. o Nitroglycerin : Sublingual nitroglycerin is used to relieve chest pain by dilating coronary arteries and reducing cardiac workload. o Beta-blockers : Used to decrease heart rate and oxygen demand of the heart. o Statins : High-intensity statin therapy (e.g., atorvastatin 40-80 mg) is recommended to lower LDL cholesterol and reduce the risk of further cardiovascular events.

CHEST PAIN

o Heparin or low-molecular-weight heparin (LMWH) : Anticoagulant therapy is important in preventing the formation of new clots. o ACE inhibitors : These are used in patients with left ventricular dysfunction or heart failure to reduce mortality and prevent remodeling of the heart. o Percutaneous Coronary Intervention (PCI) : If the patient is at high risk or if an MI is confirmed (STEMI), immediate coronary revascularization (stenting) may be required.

Guideline Reference : ACC/AHA Guidelines for the Management of Patients with Acute Coronary Syndromes Long-term Management :

• Cardiac Rehabilitation : After stabilization, the patient should be enrolled in a cardiac rehab program, which focuses on supervised exercise, heart health education, and emotional support. This reduces the risk of further cardiovascular events.
• Dual Antiplatelet Therapy (DAPT) : For patients who undergo PCI, clopidogrel or ticagrelor should be added to aspirin for up to 12 months to prevent stent thrombosis.
• Cholesterol Management : Continuous statin therapy to maintain LDL levels below 70 mg/dL is recommended.
• Blood Pressure Control : The goal is to maintain a blood pressure of less than 130/ mmHg, which may require continued use of ACE inhibitors or beta-blockers.

Guideline Reference : ACC/AHA 2019 Guidelines on Primary Prevention of Cardiovascular Disease.

and Patient Education**:

• Smoking Cessation : If the patient smokes, it’s critical to quit. Smoking damages the lining of arteries and increases the risk of coronary artery disease. Smoking cessation programs, counseling, and pharmacotherapy (e.g., nicotine replacement, bupropion) should be offered.
• Dietary Modifications : o A heart-healthy diet such as the Mediterranean or DASH diet is recommended. This includes increased consumption of fruits, vegetables, whole grains, lean proteins (especially fish), and healthy fats (like olive oil) while reducing sodium, saturated fats, and processed foods. o Limit alcohol intake to moderate levels.
• Physical Activity : Patients should aim for at least 150 minutes of moderate-intensity aerobic activity per week (e.g., brisk walking) along with muscle-strengthening exercises on 2 or more days a week.
• Weight Management : Encourage a healthy body weight (BMI 18.5–24.9). Overweight patients should aim for gradual weight loss through diet and exercise.
• Stress Reduction : Chronic stress contributes to heart disease. Mindfulness, yoga, meditation, or counseling can be part of the stress management plan.

Guideline Reference : AHA/ACC 2019 Guideline on the Primary Prevention of Cardiovascular Disease.

CHEST PAIN

NURS_6512_Week 7_Assignment_Rubric

Criteria Ratings Pts

This criterion is

20 pt s

linked to a Learning OutcomePhysical Exam: Complete an

20 pts Excellent

15 pts Good

10 pts Fair

5 pts Poor

0 pts Unsatisfactory appropriate physical Achieves a Achieves a Achieves a Achieves a Achieves a score of exam. (Scores are automatically

score of 90– 100%

score of 80– 89%

score of 70– 79%

score of 60– 69%

59% or below

calculated in the i- Human platform.)

This criterion is linked to a Learning OutcomeEMR Documentation History of Present Illness: 5 criteria: 1.) Complete; 2.) Accurate; 3.) Written in Professional Language; 4.)

10 pt s

10 pts Excellent Complete HPI meeting all 5 criteria.

8 pts Good 4 requirements are met.

6 pts Fair 3 requirements are met.

4 pts Poor 1 – 2 requirements are met.

0 pts Unsatisfactory No requirements are met.

Pertinent to the Chief Complaint; 5.) Includes Subjective findings only

CHEST PAIN

NURS_6512_Week 7_Assignment_Rubric

Criteria Ratings Pts

This criterion is

10 pt s

linked to a Learning OutcomeEMR Documentation Subjective Data Document Current Medications, Review of System: 5 criteria: 1.) Complete; 2.)

10 pts Excellent

8 pts Good

6 pts Fair

4 pts Poor

0 pts Unsatisfactory Accurate; 3.) Written Complete HPI 4 requirements 3 requirements 1 – 2 No requirements in Professional Language; 4.)

meeting all 5 criteria.

are met. are met. requirements are met.

are met.

Pertinent to the Chief Complaint; 5.) Includes Subjective findings only

This criterion is linked to a Learning OutcomeEMR Documentation Objective Data Document Physical Exam Findings: 5 criteria: 1.) Complete; 2.) Accurate; 3.) Written in Professional

10 pt s

10 pts Excellent Complete HPI meeting all 5 criteria.

8 pts Good 4 requirements are met.

6 pts Fair 3 requirements are met.

4 pts Poor 1 – 2 requirements are met.

0 pts Unsatisfactory No requirements are met.

Language; 4.) Pertinent to the Chief Complaint; 5.) Includes Objective findings only

CHEST PAIN

NURS_6512_Week 7_Assignment_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeManagemen t Plan: Use the expert diagnosis provided to create a pertinent, comprehensive, evidenced-based management plan. Address the following criteria in the plan: 1.) Diagnostic tests; 2.) Medications (write out a complete order, even for OTC meds); 3.) Suggested consults/referrals; 4.) Patient education; 5.) Follow-up, including time interval and specific symptoms to prompt a return visit

15 pts Excellent All requirements are met.

13 pts Good 5 requirements are met.

10 pts Fair 4 requirements are met.

7 pts Poor 1- requirements are met.

0 pts Unsatisfactory No requirements are met.

15 pt s

sooner; 6.) Provide rationales for each intervention and include references to support your plan. Clinical practice guidelines should be utilized as applicable.

CHEST PAIN

NURS_6512_Week 7_Assignment_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning 5 pts Excellent 0 – 1 errors Clinical practice guidelines used when applicable.

4 pts Good 2 – 3 errors Clinical practice guidelines used when applicable.

3 pts Fair 4 – 5 errors Clinical practice guidelines not used when applicable.

2 pts Poor 6 – 7 errors Clinical practice guidelines not used when applicable.

0 pts Unsatisfactory More than 7 errors; clinical practice guidelines not used when applicable.

OutcomeReferences and Format: Current APA citations for references in 5 pts management plan. Use of clinical practice guidelines when applicable.

Total Points: 100

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