FLORENCE BLACKMAN IHUMAN CASE STUDY 66-YEAR-OLD FEMALE – CHEST PAIN 2 DIFFERENT VERSIONS O, Exams of Nursing

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FLORENCE BLACKMAN IHUMAN CASE

STUDY 66 - YEAR-OLD FEMALE – CHEST

PAIN 2 DIFFERENT VERSIONS OF THE

ANSWER 2024 A+

VERSION 1

Florence Blackman (66 y/o female) – Chest Pain

• CC: Intermittent squeezing chest pain
• MSAP: Exertional “squeezing” mid-chest pain radiating to left arm, relieved by rest, worse with cold
• Associated dyspnea on exertion
• History: HLD, HTN, previous smoker, family hx of heart disease
• Stressful work History Questions:
• How can I help you today?
• Any other symptoms we should discuss?
• Do you have any allergies?
• Are you taking any OTC or herbal medications?
• Any new or recent changes in medications?
• What does the pain / discomfort in your chest feel like? (squeezing, pressure, crushing, burning, stabbing, aching, tingling, suffocating)
• How severe (scale 1 - 10) is the pain in your chest?

• Does anything make the pain in your chest better or worse?
• What are the events surrounding the start of your chest pain?
• Is there a pattern to your chest pain?
• Have you had any trauma to your chest?
• Does the pain in your chest radiate someplace else? Where?
• Do you have unusual heartbeats (palpitations)?
• Does the pain get worse with breathing?
• Does your pain awaken you from your sleep?
• Is your pain affected by what, when, or how much you eat?
• Do you presently have heartburn, a food or acid taste in your mouth?
• Do you drink alcohol? If so, what do you drink and how many drinks per day?
• Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, night sweats?
• Do you experience: SOB, wheezing, difficulty catching breath, chronic cough, sputum production?
• Does anything make your shortness of breath better or worse?
• How long does your SOB last?
• Do you have any of the following: heat or cold intolerance, increased thirst, increased sweating, frequent urination, change in appetite?
• Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor?

• Do you have problems with: N/V, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your BM, early satiety, bloating?
• How is your overall health?
• Tell me about your work.
• Tell me about daily exercise or sports that you play. Physical Exam:
• Vitals: pulse, BP, respirations
• Examine skin
• Neck: measure JVP (jugular venous pressure) - Neck: auscultate carotid arteries - Chest wall & lungs: o Visual inspection of anterior & posterior chest o Palpate anterior & posterior chest o Auscultate lungs - Heart: o Palpate for PMI (Point of Maximal Impact) o Auscultate heart - Abdomen: o Auscultate abdominal/femoral arteries o Palpate abdomen
• Extremities: Visual inspection of extremities Assessment note:
• F.B. is a 66 y/o Caucasian female presenting with 2-week h/o new onset, intermittent, stable chest pain which radiates to the L arm, occurs with SOB, is worse with cold temperatures and exertion, and improved by rest. On physical exam she is pain free with stable vital signs.

PMH risk factors include: distant history of smoking (5 pack/years), a history of HTN, and high cholesterol, and a family history of coronary vascular disease.

• Stress test: 2 - mm ST segment depression in inferior leads, 2, 3, and aVF and V3- 6 Diagnosis: Coronary artery disease: stable angina Plan:
• Determine need for coronary angiography based on stress test results and ECHO. Her Duke score of 10.5 is slightly above moderate risk, and arguments could be made for both a trial at medication intervention since the pt needs improvement on both HTN and HLD o Augment management of preexisting HTN and HLD with a BB (metoprolol 25 mg XR daily); a statin (atorvastatin 40 mg daily); and ASA 81 mg daily - Continue use of HCTZ 25 mg daily - Encourage lifestyle modification: o Decrease intensity of aerobic workouts for next 3 months o D/c alcohol for next 2 months as starts a statin
• f/u in 3- 4 weeks Ben Kapinsky (18 y/o male) – Fever
• CC: Fatigue, SOB, productive cough with yellow/green sputum
• MSAP: Hypoxia

• Tachypnea, dyspnea
• Fever and chills
• Fatigue and myalgia
• Right-sided chest wall pain aggravated by coughing
• Productive cough
• Right middle and lower lung crackles
• Bilateral cervical lymphadenopathy
• Tachycardia
• Previous hx of the flu 2 weeks ago, but got better
• Childhood asthma per history History Questions:
• How can I help you today?
• Any other symptoms or concerns we should discuss?
• Do you have any allergies?
• Are you taking any prescription medications?
• Are you taking any OTC or herbal medications?
• How high is your fever?
• When did your cough start? – 4 days ago
• Is there a pattern to your cough? – no

• Does anything make your cough better or worse?
• Are you coughing up any sputum? – yellowish green stuff
• What are the events surrounding the start of your cough? – symptoms started without much warning, thought maybe just got tired going to the party, but got worse over time
• What treatments have you had for your cough? – cough syrup, doesn’t help
• Do you awaken at night coughing? – yes, can’t sleep
• Have you had a cough like this before? – no
• Do you have any pain in your chest? – yes, here on the right side when I cough or take a deep breath (points to right thorax, 6-8th intercostal space at midaxillary line)
• How severe (1- 10 scale) is the pain in your chest? – 7 - 8 when cough or deep breathe
• Have you had any contact with other sick people? – no
• Tell me about any current or past medical problems? – none besides mild asthma
• Any previous medical, surgical, or dental procedures? – none besides fillings in teeth - Have you ever been hospitalized? – no
• Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, night sweats? – “some of that stuff for sure”
• Do you have any problems with: headaches that don’t go away with ASA or Tylenol, double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats, difficulty swallowing?
• Do you experience: chest pain discomfort or pressure; pain/pressure/dizziness with exertion or getting angry; palpitations; decreased exercise tolerance; blue/cold fingers or toes?

• Do you have problems with: N/V, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your BM, early satiety, bloating?
• When you urinate, have you noticed: pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night or any changes in frequency?
• Do you have problems with: muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, hip pain?
• Have you noticed: any bruising, bleeding gums, nose bleeds, or other sites of increased bleeding?
• Do you have any of the following: heat or cold intolerance, increased thirst, increased sweating, frequent urination, change in appetite?
• Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor?
• Do you have any problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or even hear voices or see things that you know are not there?