Alford_AQIM02_11282023 (2)
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Internal Medicine 02
Kent Alford
United States University
Primary Health of Acute Client’s
FNP593
Professor Jessica Collinsworth
11/27/2023
The case summary study this week is a 60-year-old female presenting to the primary care setting with
3-month history of anterior chest pain and significant comorbidities including hyperlipidemia obesity
with BMI of 35 kg/m2 and Hypertension. The Nurse Practitioner realizing the gravity of the clinical
presentation performs a detailed cardiac examination on the patient which includes:
1.Elevated Blood Pressure.
2.Anterior Chest pain non radiating and not reproduced with palpation.
3.Increased BMI of 35kg/m2 suggesting morbid obesity.
4.EKG revealing normal sinus rhythm with non-specific T wave changes.
5.Elevated Cholesterol level, Elevated LDL, and decreased LDL.
6.Excrcise stress test reveals ST Depression with external chest pain noted.
Differential Diagnosis
The Differential diagnosis for this case study is:
1.Pulmonary Embolus as evidenced worsening chest pain for past 3 months unrelieved by dietary
modifications[ CITATION Cas23 \l 1033 ].
2.Myocardial Infarction as evidenced by chest pain and exertional pain during stress
testing[ CITATION unp22 \l 1033 ].
3.GERD as evidenced by poor dietary choices fast food eating and chest pain[ CITATION unp22 \l
1033 ]
Diagnosis
The final diagnosis is Stable Angina Pectoris as defined by the clinical Practice Guidelines of
the American Heart Association defined as diffuse retrosternal pain lasting longer than 1 minute but not
greater than 10 minutes[ CITATION unp22 \l 1033 ].The patient also suffers from chest pain elicited on
the exercise stress test with ST depression and not ST elevation ruling out Myocardial
Infarction[ CITATION unp22 \l 1033 ]
The patient was examined by the cardiologist in the acute care setting via cardia catheterization
and discovered to have 75% occlusion of the left descending artery. The cardiac catheterization remains
uncomplicated and requires stenting of the occluded artery based on the results of the exercise stress
testing.
Diagnostics
The following tools would be used by the Nurse Practitioner to confirm the diagnosis of Stable
Angina Pectoris y using the following:
1.Detailed Physical Cardiac Examination with palpation and auscultation of cardiac
sounds[ CITATION Bic22 \l 1033 ]
2.EKG to rule out ST Elevation. This can be performed in the primary care setting[ CITATION
unp22 \l 1033 ]
2.Assessing the D-Dimer and Troponin levels to rule out Myocardial Infarction[ CITATION
Cas23 \l 1033 ]
3.D-dimer testing versus the ultrasound to rule in the presence of the thrombus[ CITATION
Bre22 \l 1033 ].
4.Exercise Stress testing to determine the level of cardiac occlusion[ CITATION unp22 \l
1033 ].
Treatment, Education, and Follow-Up
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The Nurse Practitioner realizes that once the diagnosis is confirmed the following treatment measures
will need to be implemented:
1.Give Aspirin and Nitroglycerin to address the acute symptoms of anginal chest pain[ CITATION
Cas23 \l 1033 ].
2.Give Oxygen therapy as needed to increase oxygen the cardiac vasculature[ CITATION Cas23 \l
1033 ].
3.Referral and Consultation with Cardiac services for more definitive diagnosis and
treatment[ CITATION Cas23 \l 1033 ].
4.Prescribe Plavix, Aspirin, Atorvastin, Lisinopril, Metoprolol and HCTZ post cardiac stent via cardiac
acute services[ CITATION Cas23 \l 1033 ].
5.Outpatient management with diet management and dietary modifications by the Family Nurse
Practitioner[ CITATION unp22 \l 1033 ].
Conclusion
In summary the Nurse Practitioner treats a 60-year-old female with Metabolic X syndrome
experiencing chest pain for a period of 3 months. The Physical Examination reveals unremarkable
findings with a BMI of 35kg/mg2 and poor dietary habits. Cardiac Consultation and Stress testing
reveals ST depression and a 75 % occluded cardiac vessel. The patient required cardiac catheterization
with stenting that is uncomplicated. The patient will finally require outpatient management that
includes dietary modification and disease state education.
References
Bickley, L. S. (2020). Bates' Guide To Physical Examination and History Taking (13th ed.). Wolters
Kluwer Health. https://bookshelf.vitalsource.com/books/9781975109943.
Cash, J. C. (2023). Family Practice Guidelines. Philadelphia: Springer Publishing LLC.
Dunphy, L. M.-B. (2022). Dunphy, L. M., Winland-Brown, Primary Care: The Art and Science of
Advanced Practice Nursing - and Interprofessional Approach (6th ed.). unphy, L. M., Winland-
Brown, J. E., Porter, B. O., & Thomas, D. J. (2022). Primary Care: The Art and ScienceF. A.
Davis Company. https://bookshelf.vitalsource.com/books/97817196494.
References
Bickley, L. S. (2020). Bates' Guide To Physical Examination and History Taking (13th ed.). Wolters
Kluwer Health. https://bookshelf.vitalsource.com/books/9781975109943.
Bickley, L. S. (2022). Guide To Physical Examination and History Taking. Wolters Kluwer Health,
2020.
Colalillo, G. P. (2023). Traumatic testicular dislocation in the abdomen: diagnosis and management. .
BMJ Case Reports., 16(9)https://doi.org/10.1136/bcr-2022-254530.
Dunphy, L. M.-B. (2022). Dunphy, L. M., Winland-Brown, Primary Care: The Art and Science of
Advanced Practice Nursing - and Interprofessional Approach (6th ed.). Dunphy, L. M.,
Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2022). Primary Care: The Art and
ScienceF. A. Davis Company. https://bookshelf.vitalsource.com/books/97817196494.
Kudzma, C. E. (2022). Health Promotion Throughout the Life Span (9th ed.). Kudzma, C.E. E. ([Insert
Year of Publication] Elsevier Health Sciences (US).
https://bookshelf.vitalsource.com/books/9780323416733.
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