Throat, Respiratory & Cardiovascular Disorders

For this Discussion, you will take on the role of a clinician who is building a health history the following case.
Case 3
Chief Complaint
(CC) A 75-year-old female reports experiencing pain in her chest while walking up steps today.
Subjective Could not sleep previous night. Feels like an ache or a burning sensation at the center of sternum. Denies any arm pain, pain was at a scale of 8 in the AM now it is at a 2. Suffers from History of hypertension, denies heart disease, denies leg swelling up, denies pain feeling worse when taking deep breath.
VS BP 129/70, (HR) 72 and regular, (RR) 16 unlabored, temperature 98.8°F, oral pulse oximetry is 99%
General obese female, alert, in no acute distress.
HEENT Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.
Respiratory CTA AP&L
Neck/Throat carotids are 2+ without bruits; thyroid is not palpable; no lymphadenopathy
Heart S1 and S2 normal without murmur, gallop, or rub

Answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms.
5. Give rationales for each differential diagnosis.
Submission Instructions:
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

Answer

Subjective

History of presenting illness: I would ask about the onset of the chest pain. Was it gradual or sudden in onset? I would like to know how long the pain lasts. I would also like to know if the pain is constant or fluctuating. I would also like to know if the pain radiates to the other parts of the body, such as the neck or jaws. Are there any associated symptoms such as shortness of breath, sweating, or vomiting? Does the patient have palpitations? Is there a cough associated with the chest pain, and if present, is it productive or blood-stained? Are there any factors that exacerbate the pain?

Past medical history: I would ask about any history of diabetes mellitus, hyperlipidemia, or history of stroke. I would like to know if the patient has had any recent surgeries that may predispose her to a thromboembolic event.

Medication history: I would like to know if the patient is currently taking any prescribed medications that might be relevant to chest pain. These include ACE inhibitors, calcium channel blockers, and Statins. I would also like to know if the patient takes hormone replacement therapy.

Family history: I would ask about a history of cardiovascular disease, stroke, or thromboembolic disease in the family.

Social history: I would like to know the type of accommodation the patient resides in. I would also want to know who they live with and if they have a personal support network.

I would enquire about any history of smoking, alcohol use, or recreational drug use.

Health promotion: I would ask about the patient’s diet. I would also ask the patient’s level of activity and if the patient exercises.

Objective

I would examine the pulses. I would check the skin for diaphoresis. I would check for abdominal tenderness.

Diagnostic exams

I would order a complete blood count to check for anemia or leukocytosis, which may indicate an infection.

I would order Blood sugar to rule out diabetes. I would also order Lipid levels to rule out dyslipidemia. I would order cardiac biomarkers such as troponin I and T.

I would order an electrocardiogram (ECG). I would also order a chest x-ray. I would order a CT pulmonary angiogram.

Differential Diagnoses

  1. Myocardial ischemia
  2. Acute coronary syndrome
  3. Pulmonary embolism

Myocardial ischemia occurs due to an imbalance between oxygen demand and oxygen supply in the myocardial cells. This usually presents as angina. Patients often describe chest pain as retrosternal in nature and can be described as a heaviness in the chest. This pain may or may not radiate to other parts of the body, such as the arms and the jaws. The pain is often provoked by exertion such as climbing the stairs, as in this patient’s case. This pain is relieved by rest. The pain is constricting in nature. Other symptoms may include breathlessness and symptoms of fatigue. The patient may also have additional findings such as abdominal discomfort, palpitations, and syncope (Anderson & Morrow, 2017).

Acute coronary syndrome also presents with substernal chest pain. This is the classic symptom. The pain is described as crushing, and it radiates to the jaw or left arm. The symptoms can sometimes be vague and subtle, and the patient can present with difficulty in breathing as the chief complaint. Other symptoms may include diaphoresis, nausea, weakness, and lightheadedness. One of the risk factors is being an older female (Mehilli & Presbitero, 2020).

Pulmonary embolism is also characterized by pleuritic chest pain that is sudden in onset. It causes breathlessness and hemoptysis.

References

Anderson, J. L., & Morrow, D. A. (2017). Acute Myocardial Infarction. The New England Journal Of Medicine376(21), 2053–2064. https://doi.org/10.1056/NEJMra1606915

Mehilli, J., & Presbitero, P. (2020). Coronary artery disease and acute coronary syndrome in women. Heart (British Cardiac Society)106(7), 487–492. https://doi.org/10.1136/heartjnl-2019-315555

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