Advance Practice

Advance Practice

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Apply information from the Aquifer Case Study to answer the following discussion questions:

Discuss the history of present illness that you would take on this patient in preparation for the clinic visit. Include questions regarding Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity (OLDCARTS). 

•Describe the physical exam and diagnostic tools to be used for Ms. Johnston. Are there any additional you would have liked to be included that were not?

•What plan of care will Ms. Johnston be given at this visit; what is the patient education and follow-up?

Do Two pages.

Provide References.

See attached Aquifer Case Study.

7/13/19, 3(41 PMInternal Medicine 02: 60-year-old woman with chest pain – South Univ…ollege of Nursing and Public Health Graduate Online Nursing Program

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South University College of Nursing and Public Health Graduate Online

Nursing Program

Aquifer Internal Medicine

Internal Medicine 02: 60- year-old woman with chest pain

Author:Author: Kirk A. Bronander, MD; Associate Editor, Amy E. Blatt, MD; Case Editor, Amalia Landa-Galindez, MD

INTRODUCTION CARE DISCUSSION

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

MENUMENU

7/13/19, 3(41 PMInternal Medicine 02: 60-year-old woman with chest pain – South Univ…ollege of Nursing and Public Health Graduate Online Nursing Program

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Dr. Lorenzen asks Dr. Lorenzen asks you to see Ms. Johnston.you to see Ms. Johnston.

!

You are working with Dr. Lorenzen, who asks you to start interviewing Susan Johnston, a patient she knows well who is here to discuss recent symptoms of chest pain.

DIFFERENTIAL DIAGNOSIS CLINICAL REASONING Before seeing the patient, Dr. Lorenzen asks you to review the differential diagnosis for chest pain. She reminds you, “There are many causes of chest pain including cardiac, gastrointestinal, pulmonary, musculoskeletal and psychogenic causes.”

Question List below three potential causes of chest pain in each of the categories mentioned.

7/13/19, 3(41 PMInternal Medicine 02: 60-year-old woman with chest pain – South Univ…ollege of Nursing and Public Health Graduate Online Nursing Program

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The suggested answer is shown below.

Pericarditis, Myocardial Infarction, Aortic Dissection, GERD, Esophageal Spasm, Heart Burn, Pneumonia, Pleuritis, Flu, Costochondritis, Trauma, Lower Rib Pain Syndrome, Anxiety, Hyperventilation, Depression.

Letter Count: 207/1000

SUBMITSUBMIT

Answer Comment See Teaching Point below

Broad DiIerential Diagnosis of Chest Pain

CardiacCardiac

Cardiovascular Causes of Chest PainCardiovascular Causes of Chest Pain

SymptomsSymptoms SignsSigns OtherOther abnormalitiesabnormalities

AnginaAngina

Chest pressure that may radiate to neck/arm/shoulder. May have associated

May have abnormal blood pressure, lower

May have ST segment

TEACHING POINTTEACHING POINT

7/13/19, 3(41 PMInternal Medicine 02: 60-year-old woman with chest pain – South Univ…ollege of Nursing and Public Health Graduate Online Nursing Program

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Pectoris/CoronaryPectoris/Coronary Artery DiseaseArtery Disease

dyspnea. Risk factors include obesity, diabetes, hypertension and hyperlipidemia.

extremity edema, cardiac murmurs or normal exam.

abnormalities on EKG.

Variant AnginaVariant Angina

Vasospastic cause of angina, often younger pt with few risk factors. Risk factors include tobacco use.

Between episodes of chest pain physical exam may be completely normal.

Accompanied by transient ST elevation on EKG.

Cocaine InducedCocaine Induced Chest PainChest Pain

Chest pain after cocaine use from infarction or intense coronary spasm.

Patients may have burn marks on lips and fingers from crack pipe, needle marks on skin from injections, and/or inflammation and ulcerations in the pharynx and nasal septa.

Urine tox screen positive for cocaine and drug metabolites. Elevated CPK levels may be seen with associated rhabdomyolysis.

Aortic DissectionAortic Dissection

Crushing or tearing quality pain in center of chest, radiates to back.

Murmur of aortic insufficiency may be present.

Widened mediastinum on CXR.

7/13/19, 3(41 PMInternal Medicine 02: 60-year-old woman with chest pain – South Univ…ollege of Nursing and Public Health Graduate Online Nursing Program

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Valvular HeartValvular Heart DiseaseDisease

Aortic stenosis can result in anginal pain. Mitral prolapse patients often have atypical chest pain.

AS – systolic crescendo decrescendo murmur, MVP – midsystolic click with possible late systolic murmur.

PericarditisPericarditis

Severe retrosternal, often pleuritic, pain that varies with body positioning.

Pericardial friction rub.

Diffuse ST elevation and PR depressions on EKG, pericardial effusion on echocardiogram.

Non-ischemicNon-ischemic CardiomyopathyCardiomyopathy

Usually does not manifest as chest pain but rather dyspnea or other CHF symptoms.

Pulmonary edema, hepatic congestion, lower ext edema, jugular venous distension.

Enlarged heart on CXR, elevated b- type naturetic peptide.

CardiacCardiac Syndrome XSyndrome X

Exertional angina- like chest pain, more common in women.

Usually normal EKG, abnormal exercise stress test with normal coronaries on angiogram and no evidence of coronary spasm.

Similar to

7/13/19, 3(41 PMInternal Medicine 02: 60-year-old woman with chest pain – South Univ…ollege of Nursing and Public Health Graduate Online Nursing Program

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MyocarditisMyocarditis pericarditis but can also mimic ischemia.

May manifest as CHF.

Cardiac enzymes may be elevated.

GastrointestinalGastrointestinal

Gastrointestinal Causes of Chest PainGastrointestinal Causes of Chest Pain

SymptomsSymptoms SignsSigns Other AbnormalitiesOther Abnormalities

EsophagealEsophageal DiseaseDisease

Reflux associated chest pain usually occurs after meals, is exacerbated by lying down or bending over, and improved by antacids. May be associated with chronic cough.

May be associated with laryngitis or posterior oropharyngeal erythema in severe cases.

BiliaryBiliary

Usually presents with right upper quadrant or epigastric pain. Pain may be

Murphy’s sign – tender palpable gallbladder with a sudden halt of Abnormal liver function

7/13/19, 3(41 PMInternal Medicine 02: 60-year-old woman with chest pain – South Univ…ollege of Nursing and Public Health Graduate Online Nursing Program

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DiseaseDisease exacerbated by fatty foods and may be accompanied by nausea and/or vomiting.

inspiration with palpation in the upper quadrant. Occasional jaundice

tests

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