Case Study: Karen Barnes - Chest Pain and Dyspnea, Exams of Nursing

Download Case Study: Karen Barnes - Chest Pain and Dyspnea and more Exams Nursing in PDF only on Docsity! Karen Barnes Ihuman case Study reason for chest pain and dyspnea Advanced Health Assessment Instructions: Type patient encounter information directly into each box of the template. Students should avoid the use of the following terms: “WNL”/”Normal”, etc and should document systems with s have provided on previous cases into each subsequent assig CC: 49-year-old female Chief complaint is a short 1-2 statement or word phrase from patient and should be listed in “quotes” “Exertional mid-chest pain that radiates to left arm with a squeezing quality” HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts PMHx child/adult illness/hospitalizations/immunizations History of hypertension and high cholesterol Missed this year’s flu vaccination Location: Mid chest that radiates to left arm ecificity and accuracy. Students are also expected to incorporate any feedback faculty ment. Ms. Barnes is a 49-year-old female with chest pain and dyspnea that started 2 weeks ago during a ski run activity in the cold. She reports that the chest pain radiates to the left arm and has a squeezing quality to it. The pain is exacerbated by fast walking in the cold and relieved by resting. Onset: Chest pain 2 week ago during a cross-country ski run Duration: The chest pain comes and goes. Lasts several minutes and occurs1-2 times a week Character: Chest pain with a squeezy quality and radiates to the left arm. Pain scale of 5 or 6 on scale of 1-10 Aggravating/alleviating factors: Precipitated by exercise and improves with rest Related symptoms: Dyspnea that occurs with chest pain with exertion Case: 165484 Karen Barnes Date: Treatments: Nothing Father died at age 65 of stroke Significance: Chest pain in someone with her medical and family history can indicate a serious problem SurgHx type/when/why/complications No surgical history FamHx Mother died at age 54 with heart disease Older sister age 58: recent open-heart surgery SHx Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships ETOH: Drinks 1-2 glasses of wine each night Tobacco: Previous smoker: Quit 15 years ago Denies use of recreational drugs Grandparents (if known)/Parents/siblings/children Reproductive Hx Female: Age of menarche/menstruation cycle duration/gravida para status/Childbirth hx/sexual hx and concerns/LMP/menopause Breast/cervical screening (if any) Male: Sexual hx and concerns/issues with fertility (if any)/Testicular or prostate screening (if applicable) Screening for STI’s (if applicable) Up to date for cancer screening for gender. Annual gynecological exam normal Not currently sexually active Patient reports a very stressful job Allergies (Food, Drug, Environmental, etc.) No known allergies List of Medications/supplements (prescription, OTC, complementary alternative therapies) Hydrochlorothiazide 12.5mg daily Review of Systems: (ROS) Use this column to document the ROS below. General: Chest pain with dyspnea, denies fatigue, weakness, sleep disturbance HEENT: No complaint of headache, vision problem, ear pain or sinus problems Pulmonary: shortness of breath with exertion, denies wheezing From the ROS: list/highlight the current symptoms/complaints to generate a list of pertinent “reported or denied” symptoms below: Case: 165484 Karen Barnes GI: abdomen not tender and bowel sounds present in all 4 quadrants GU: negative for any urinary problems LDL cholesterol Blood glucose: normal Cardiac stress test: ST segment depression Echocardiogram: Normal cardiac structure and function CK-MB: Normal Neuro: Alert and oriented X 4 Derm: Skin turgor normal. Skin warm and dry with no lesions MSK: Normal bulk and tone Psych: Not assessed Lab/Radiology or other Diagnostic data: 12 lead electrocardiograms: Normal sinus rhythm, no ST elevation abnormalities Troponin T: within normal values CBC: all labs within normal values Lipid profile: elevated cholesterol, and elevated IHUMAN TOTAL CASE SCORES: #1: 71% #2: 95% Based on patient’s age/risk factors, what Problem Statement: Ms. Barnes is a 49-year-old female with chest pain and dyspnea that started 2 weeks ago during a ski run activity in the cold. She reports that the chest pain radiates to the left arm and has a squeezing quality to it. The pain is exacerbated by fast walking in the cold and relieved by resting. She has a history of hyperlipidemia and hypertension. She has a previous history of smoking and a family history of coronary vascular disease. She is slightly overweight; the remainder of exam is unremarkable. Physical examination indicated elevated BP. EKG is normal with no ST elevation abnormalities. Troponin, CBC, lipid profile, CK-MB were normal Cervical cancer screening for women aged 2165 years Grade B Recommendations- Screening for Depression/Mood Disorders in adults List the (reports stress at today’s visit) differential diagnoses (Must Miss/Leading/Alternate/Concluding) *Include ICD 10 codes after each preventive scre would be recommended at today’s or a future vi not Healthy diet and physical activity for prevention of CVD in ening adults with risk factors Skin Cancer prevention annually sit: Screening for unhealthy alcohol/drug use in Grade A Recommendations: High Blood Pressure adults over age 18. Check periodically for evidence of elevated b/p readings (slightly elevated b/p likely related to pain) adolescents/adults Screening for type 2 diabetes in adults aged 40 to 70 years who are overweight or obese Case: 165484 Karen Barnes Miss/Leading: (USPSTF, 2021) Must Not Gastroesophageal reflux (K21.9): The exertional quality of the patient’s symptom rules out GERD Stable Angina (I20.9): Chest pain and dyspnea with exertion that is relieved at rest. Unstable Angina (120.0): The recurrent chest pain was stable and not representative of unstable angina Alternate: Esophageal spasm (K22.4): symptoms mimic anginal chest pain, but not indicative for Ms. Barnes Costochondritis (M94.0): Patient did not complain of symptoms indicative of this diagnosis Concluding: Stable Angina (I20.9): The subacute nature of chest pain and dyspnea more indicative of stable (Gillen, 2020). *Case Study Template adapted from the following sources: NP H & P (ReNursing.edu, 2018) and IHuman Patients by Kaplan (2020) Case: 165484 Karen Barnes Date: Reflective Thinking Exercises (start a new page) 1. History-Taking: Describe your history taking scores and strengths you identified when gathering data. What went well? Also, describe your challenges in gathering data and list areas of your personal needed improvement. Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis. I find that even when the patient has answered the question you are still required to ask a specific question to get all the points. I feel like I focused my questions using Dain’s and I still did get most of the questions. My score from the first attempt was 57% and 100% for the second attempt. I discovered that the question you have already askes has previously asked question notated after the question; that will help me in the next case. 2. Physical Exam: Describe your physical exam scores and strengths you identified when performing selected exams on your patient. Did you perform an excessive amount of exam items? Did you miss any pertinent exam items identified in the case leading to diagnosis? Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis. Difficulty identifying heart sound was difficult because there was another sound that could be heard behind the normal heart sounds. First attempt scores 87% and second attempt was also 87%. 3. Evidence-based decision making: Discuss the evidence-based resource(s) utilized while seeing the patient. These can be your course readings/IHUMAN lessons/other course info as well as any external articles or supporting literature to help you gain a better understanding of categorizing possible diagnoses in your case. How did you use the symptoms/patient presentation, plus your exam findings, to formulate a differential diagnosis list? What specific feedback from previous case studies has your faculty identified that you plan to incorporate on future cases to avoid pitfalls in data gathering or decision making? What will you do differently to improve? The required text readings from S2D and Dain was very beneficial especially S2D with identifying differential diagnosis. Based on the use of these tools, I don’t agree that pulmonary embolism, esophagitis are not plausible differential diagnosis, The patient’s symptom is not really point to costochondritis * e