Nursing

write a treatment management/ plan according to scenario

CASE:

FM is a 62 years old man who presents with a two months of chest pressure/pain that radiates to cause “throat tightness”. Episodes occurs with exertion or emotional upset and are relieved by rest. He denies palpitations, lightheadedness or syncope but had SOB and diaphoresis during one episode. PE is positive for HTN R carotid and L femoral bruits no cardiac murmur or edema. PMH includes HTN, elevated cholesterol levels treated with diet alone due to medication side effects, and > 50 pack year history of smoking. FH is significant for both parents dying of CVD and now an older sister s/p MI.

BASED on description of his chest discomfort and laboratory findings, the diagnosis is stable angina. The presence of carotid and femoral bruits suggested arterial disease due to atherosclerosis that correlates well his elevated total cholesterol which is 257 . therefore, atheromatous plaque is also likely to be presents in the coronary arteries. The fact that his ECG and echocardiogram are normal merely indicates that he has not had previous MI resulting in permanent myocardial damage or scar formation. The nuclear study suggest he does have an exercise induced perfusion defect which increase his risk of having a MI.

On current medication: Hydrochlorothiazide 25 mg daily

PRIMARY DX:

STABLE ANGINA

DIFFERENTIAL DX:

1.UNSTABLE ANGINA

2.GERD

3.ESOPHAGEAL SPASM

ANSWER

Treatment and Management Plan

In reference to the laboratory results and the description of the patient’s chest discomfort, the primary diagnosis is stable angina. This diagnosis is based on the availability of carotid and femoral bruits which suggest the presence of arterial disease; which is majorly due to atherosclerosis hence his elevated cholesterol, 257. This creates a possibility of the existence of atheromatous plaque in the coronary arteries. Some of the reasons in support of the primary diagnosis are the occurrence of the throat tightness with exertion and or emotional upset which are then relieved by rest. The patient has also experienced SOB and diaphoresis during one of the previous episodes. The other three diagnosis include unstable angina, esophageal spasm and gerd. One of the major reasons of choosing the three diagnosis is the presence of chest pain as a common symptom. Factors used to eliminate unstable angina as the primary diagnosis include the lack of dizziness, anxiety and fatigue complaints from the patient; the diagnosed chest pains did not radiate to the upper extremities and the pain wasn’t sharp. The eliminating factors for esophageal spasm were the absence of heartburn and throat problems like difficulty in food swallowing. Finally, the factors used to eliminate gerd were the absence of symptoms like heartburn and throat complications like difficulty in food swallowing (Parizadeh et al., 2018).

Some of the additional laboratory tests carried out were on blood pressure accompanied with electrocardiogram to evaluate the heart’s function, computed tomography (CT) scans to give an image of the heart; coronary angiography to evaluate blood flow in the arteries and finally blood cholesterol profile to assess the potential risk factors. The nuclear study showed the existence of an exercise induced perfusion defect thereby increasing chances of contracting myocardial infarction. C-reactive protein tests are also recommended to determine the risks of contacting heart disease. Some of the recommended consultations are seeking the guidance of a nutritionist to help in making healthful lifestyle choices, for instance consuming a diet rich in whole grains, vegetables and fruits. The patient should also visit yoga classes and physical therapy lessons. The patient should also visit a hematologist to check on the blood circulation and function (Manolis et al., 2016).

The therapeutic modalities for managing stable angina include patient education, evidence-based pharmacological treatments and risk factor medication; which play primary roles in moderating the morbidity and mortality in coronary artery disease. The major aim of pharmacological management is to mitigate cardiovascular events through growth minimization of coronary atherosclerotic plaque disease, arrest of thrombosis and equalization of plaque. The major non-pharmacological management is the application of Enhanced External Counter Pulsation (EECP) principle which lowers systolic arterial pressure, enlargement of arterial pressure and increases venous remittance. The EECP involves procedural inflation and fast deflation of compaction cuffs around the patient’s thighs, lower abdomen and calves which is timed to the cardiac cycle using electrocardiogram (Thadani 2016).

Some of the potential risk factors involved with stable angina are diabetes, smoking, high blood pressure, a history of heart disease and obesity. The older people should make frequent visits to yoga and physiotherapy lessons to ensure stable blood floor in the system. Some of the most recommended pieces of advice are consistent attendance of yoga classes and maintenance of balanced and doctor-recommended nutrition diet. The family members should ensure frequent hematologist advice to ensure standard and recommended blood flow for the patient. The patient should stay on hydrochlorothiazide 25mg daily medication until advised otherwise by a medical specialist. In case of any emergency, the patient is advised to call 911 to access the nearest emergency department immediately due to high probabilities of heart attack occurrence.

Reference

Parizadeh, S. M., Ferns, G. A., Ghandehari, M., Hassanian, S. M., Ghayour‐Mobarhan, M., Parizadeh, S. M. R., & Avan, A. (2018). The diagnostic and prognostic value of circulating microRNAs in coronary artery disease: A novel approach to disease diagnosis of stable CAD and acute coronary syndrome. Journal of cellular physiology, 233(9), 6418-6424.

Manolis, A. J., Poulimenos, L. E., Ambrosio, G., Kallistratos, M. S., Lopez-Sendon, J., Dechend, R., … & Camm, A. J. (2016). Medical treatment of stable angina: a tailored therapeutic approach. International Journal of Cardiology, 220, 445-453.

Thadani, U. (2016). Management of stable angina–current guidelines: a critical appraisal. Cardiovascular drugs and therapy, 30(4), 419-426.

Hoorweg, B. B., Willemsen, R. T., Cleef, L. E., Boogaerts, T., Buntinx, F., Glatz, J. F., & Dinant, G. J. (2017). Frequency of chest pain in primary care, diagnostic tests performed and final diagnoses. Heart, 103(21), 1727-1732.