Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.? Consider the patients diagnosis. Stable Angina. T
- Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
- Consider the patient’s diagnosis. Stable Angina. Think about clinical guidelines that might support this diagnosis.
- Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with cardiovascular conditions.
atherosclerosis
185cm
85.5 kg
SpO2: 95%
Temo: 98.6
CC: “Chest pain”
Darius Davis is a 62-year-old African America male who present to the clinical with new
intermittent chest pain. He states the onset was two months ago while raking leaves that
subsided after 10 mins of rest. Darius is able to precisely locate the pain to his midsterum. He
states the pain is intermitted with exertion and occurs three or four times a week. Pain is
characterized as a pressure or heavy weight. He has tried taking antacids and massaging the
chest to alleviate the pain with no relief. The pain has radiated to his neck on a few occasions
when he continues to exerted himself in an attempt to work through the pain. He also states once
he had shortness of breath with the pain that resolved with rest. Pain severity is a 5 or 6 on a
pain sale of 1-10. He denies fever, increased pain with inspiration, post meal, or while laying
flat.
Hctz 25mg daily – takes most of the time
Hypertension controlled on meds
Hypercholesterolemia treated with diet due to medication side-effects GERD
– occasional, treats with anti-acids
Family hx of heart disease:
Father: deceased at age 68; CAD/multiple MIs
Mother: deceased at age 71; CVA
Younger brother: age 58; DM
Older sister: age 71; CAD, MI- 3 stents
Smoker since 14, >50 pack year history
Socially drinks a few beers after work once or twice weekly Does
not exercise
He is a geologist and increased stress of work due to cut backs. 20 to
30 questions max!
Temp: 98.6 F
Pulse: 76, rhythm:
regular
BP: left: 130/84
Resp ira t io n : 12, effort:
unlabored
Additional labs or diagnostic tests:
12 lead ECG – “The ECG is central to the evaluation of stable angina in the office setting to
ensure that ACS is not missed (Gulati et al., 2021).”
Chest x-ray –“In patients presenting with acute chest pain, a chest radiograph is useful to
evaluate for other potential cardiac, pulmonary, and thoracic causes of symptoms (Gulati et al.,
2021).”
Coronary computed tomography angiography (CCTA)-“ For intermediate-high risk patients
with stable chest pain and no known CAD, CCTA is effective for diagnosis of CAD, for risk
stratification, and for guiding treatment decisions (Gulati et al., 2021).”
Lab test results can be helpful in determining whether a patient's signs and symptoms are cardiac
in nature and the level of cardiac risk include:
Fasting lipid
profile
Hemoglobin A1C
Comprehensive metabolic
panel Thyroid function test
Coronary artery calcium
score Complete blood cell
count.
CRP
High-sensitivity C-reactive protein (hs-CRP) has emerged as a leading biomarker of CVD risk
prediction (Rogers, & Baker, 2020). Obtaining a coronary artery calcium score for patients at risk
can aid compliance for patient who are hesitant to begin or rechallenge statin therapy (Rogers, &
Baker, 2020)
Consults:
Refer to cardiology: In patients where the optimal treatment strategy is indistinct and/or the
severity of risk factors put the patient at significant risk a referral to cardiology is appropriate to
improve patient outcome (Alonso, Cuevas, & Cafferata, 2019).
Therapeutic modalities:
Continue HCTZ 25mg
daily Will add:
Nitroglycerin 1 tab sublingual with onset of pain; may repeat in 5 mins for a max of 3 tabs over
15 mins.
Aspirin 81mg PO once daily
Felodipine XR 2.5mg PO once daily on empty stomach
Pravastatin 10mg PO once daily at HS
Eliminating or reducing risk factors for cardiovascular disease are a vital component in the
management for with stable angina. A strong interaction exists between CAD and hypertension
that accounts for 25%-30% of acute myocardial infarctions (Unger et al., 2020). The patients’
blood pressure is not at goal with the monotherapy of HCTZ, given his race as an African
American male it is appropriate to add a calcium channel blocker. Furthermore, the addition of a
calcium channel blocker will also improve anginal symptomatology by causing coronary and
peripheral vasodilation and reducing contractility (Williams et al., 2018). Calcium channel
blockers are second line treatment for angina however, given the patients possible respiratory
issue based on physical assessment calcium channel blockers are preferred in patients with
obstructive airways disease (Rogers, & Baker, 2020). To aid in management of acute angina the
addition of short acting nitrates is the first line therapy (Kannam, Aroetsy, & Gersh, 2021). The
optimal management of patients with angina requires more than antianginals to reduce the risk of
MI, stroke or death. Risk factor reduction includes antiplatelet, lipid lowering therapy and
lifestyle modifications (Kannam, Aroetsy, & Gersh, 2021). The patient is high risk for
cardiovascular events due to the progression of atherosclerosis, poor diet, smoking, alcohol
consumption and stress. The patient’s cholesterol is critical and must be addressed.
Nevertheless, the patient states he previously had issues with a statin, but before considering the
use of a second-line alternative drug it is appropriate to rechallenge statin therapy as in most
cases, rechallenging with a different or lower dose statin is successful (Alonso, Cuevas, &
Cafferata, 2019). Therefore, pravastatin 10 mg once daily at bedtime will be initiated due to it
being hydrophilic and is one of four statins recommended by the ACC/AHA 2018 guidelines for
patients who cannot tolerate moderate to high dose statins (Alonso, Cuevas, & Cafferata, 2019).
Nonpharmacologic Management:
Therapeutic lifestyle changes:
Encourage use of resources such as: American Heart Association’s lifes simple 7
(http://www.heart.org/en/healthy-living/healthy-lifestyle/my-life-check–lifes-simple-7)
Dietary Interventions: Encourage the Mediterranean and DASH diet
Limit saturated and trans-fat to 5-6% of calories and replace with healthier fats:
polyunsaturated and monounsaturated
Limit sodium to 2,400mg or less daily
Increase fruits and vegetables, whole grains, nuts/legumes, fish, and lean vegetable or animal
protein
Avoid red meat
Limit sugary drinks and sweets
Physical activity: 30 to 60 minutes of moderate intensity aerobic activity 5-7 days per week;
resistance training at least 2 days per week.
Smoking cessation
Health Promotion:
Per the USPSTF age is one of the most important risk factors for colorectal cancer recommends
screenings for colorectal cancer in all adults aged 50 to 75 with increased risks for African
Americans, men, and long-term smokers (USPSTF, 2021).
“The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop
using tobacco, and provide behavioral interventions and US food and Drug Administration-
approved pharmacotherapy for cessations to nonpregnant adults who use tobacco” (USPSTF,
2021).
“The USPSTF recommends offering or referring adults with cardiovascular disease risk factor to
behavioral counseling interventions to promote a healthy diet and physical activity” (USPSTF,
2021).
“The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70
years who have overweight or obesity. Clinicians should offer or refer patients with prediabetes to
effective preventive interventions” (USPSTF, 2021).
“The USPSTF recommends 1- time screening for abdominal aortic aneurysm with ultrasound in
men aged 65 – 75 who have ever smoked” (USPSTF, 2021).
“The USPSTF recommends exercise interventions to prevent falls in community dwelling adults
65 years or older who are at increased risk for falls” (USPSTF, 2021).
“The USPSTF recommends screening for depression in the general adult population (USPSTF,
2021).
“The USPSTF recommends annual screenings for lung cancer with low-dose computed
tomography in adults aged 50 to 80 years who have a 20-pack year smoking history and currently
smoke or have quit within the past 15 years” (USPSTF, 2021).
Immunizations due: Influenza and Shingrix.
Patient education:
The patient and family will be educated on new medications and importance of compliance. An
in-depth discussion on benefits versus risk possible side effects/ complications; additionally,
what to expect for future appointments.
Smoking is a modifiable risk factor that increases risk to cardiovascular events. Cessation of
smoking is critical for the patient. We will discuss nonpharmacological management including
the patients’ personal willingness or concerns with quitting; especially weight gain as well as
triggers. Provide resources such as ACC decision pathway for tobacco cessation
http://www.onlinejacc.org/content/72/25/3332.
What is Angina?: High cholesterol causes the blockages or narrowing in the vessels. These
blockages or narrowing decrease blood which carries the oxygen our tissues need. Angina is
chest pain or discomfort due to lack of oxygen to the heart muscles when there is a blockage or
narrowing to the vessels of heart. Physical activity causes the heart to pump faster increasing
need for more oxygen but the blocked vessels decrease oxygen thus resulting in the pain.
Blockages or narrowing within the hearths vessels is known as coronary heart disease.
New medication Education:
Nitro SL: improve blood flow by relaxing and expanding veins and arteries. Sublingual or under
the tongue nitro is usually recommended to treat sudden attacks of angina and to prevent angina
while engaging in activities that typically trigger angina. Will effective within two to five
minutes and its effects last 15 to 30 minutes. You may repeat the dose of nitro for a total of two or
three doses five minutes apart before calling 911. If chest pain lasts more than five minutes after
taking up to three nitro pills, call 911 immediately.
Pills should be stored in a dark, tightly capped bottle in the refrigerator; you should carry a small
number with you at all times. An unopened nitroglycerin bottle is good for one year. The
combination of nitrates and medications for erectile dysfunction is particularly hazardous since the
combination may produce a severe decrease in blood pressure. Erectile dysfunction medications
must be avoided while taking a nitrate medication
Felodipine XR: This is a dihydropyridine calcium channel blockers and it works to dilate blood
vessels and slightly decrease the strength of the heart's contractions. Side effects include:
flushing, dizziness and lightheadedness, headache, and swelling of the feet and ankles please
report these symptoms. DO NOT CRUSH OR CHEW TABLETS. Take on an empty stomach
food will decrease level on drug available for your body to use. Do not consume grapefruit juice
while on medication it will cause serious interactions.
Aspirin: Heart attacks are usually the result of a blood clot forming inside a narrowed vessel of
the heart. Aspirin helps to prevent these clots from forming which lowers the risk of a heart
attack. Bleeding is the main side effect of aspirin, please report if you have very dark stools,
frequent nose bleeds, increased bruising or any other signs of bleeding.
Pravastatin: Due to history of dyslipidemia or “high cholesterol”, worsening bruits, decreased
color/hair to lower extremities and decreased peripheral pulses restarting a statin is appropriate.
Pravastatin helps lower blood levels of "bad" cholesterol (LDL), to increase levels of "good"
cholesterol (HDL), and to lower triglycerides – a type of fat in the blood. Reducing the
cholesterol lowers the risk of stroke, heart attack, and other heart complications. Avoid drinking
alcohol it can increase your risk of liver damage. Take medication at the same time every night.
Avoid grapefruit as it may interact with pravastatin and lead to unwanted side effects.
Pravastatin can rarely cause a condition that results in the breakdown of skeletal muscle tissue,
leading to kidney failure. Report symptoms of unexplained muscle pain, tenderness, or
weakness especially if you also have fever, unusual tiredness, yellowing of eyes, or dark colored
urine.
Disposition/follow-up instructions:
Follow up with cardiology within two weeks.
Patient is to monitor blood pressures at home and keep a log: Two readings 1 minute apart each
morning before medication and each evening before dinner.
Follow up in 4 weeks: Patient is to have labs repeated CMP, CBC and fasting lipids before
follow up appt. We will further discuss smoking cessation and steps if any were taken in the
past four weeks to effectively quit. I will then explore pharmacologic management with patient
pending willingness.
Patient will be further educated that people with angina have an increased risk for a heart attack,
cardiac arrest, and sudden cardiac death. Call an ambulance immediately if he experiences new,
worsening, or persistent pain or pressure in the center of the chest, shortness of breath, nausea,
vomiting, and pain that radiates from the chest into the teeth, jaws, shoulders, or arms.
Additionally, with new medications patient is to monitor for signs and symptoms of allergic
reactions that occur within an hour of taking medication including but not limited to fever, hives,
shortness of breath, sneezing, chest tightness, sudden cough, wheezing, swollen lips, tongue, eyes
or face. Call 911 or go to closest emergency room if this occurs.
Alonso, R., Cuevas, A., & Cafferata, A. (2019). Diagnosis and Management of Statin
Intolerance. Journal of atherosclerosis and thrombosis, 26(3), 207–215.
https://doi.org/10.5551/jat.RV17030
Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. K., . . . Shaw, L.
J. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and
Diagnosis of Chest Pain: Executive Summary. Journal of the American College of
Cardiology, 78(22), 2218-2261. doi:10.1016/j.jacc.2021.07.052
Kannam, J., Aroetsy, J., & Gersh, B. (2021, June 3). Chronic coronary syndrome: Overview of
care. https://www.uptodate.com/contents/chronic-coronary-syndrome-overview-of-care?
search=angina&source=search_result&selectedTitle=2~150&usage_type=default&display_rank
=2
Orringer, C. E., Blaha, M. J., & Stone, N. J. (2021). Coronary artery calcium scoring in patients
with statin associated muscle symptoms: Prescribing statins for those most likely to
benefit. Journal of Clinical Lipidology, 15(6), 782–788.
https://doi.org/10.1016/j.jacl.2021.09.052
Rogers, J., & Baker, M. (2020). Understanding the most commonly billed diagnoses in primary
care: Atherosclerotic cardiovascular disease. The Nurse Practitioner, 45(7), 35.
https://doi.org/10.1097/01.NPR.0000669136.88720.65
U.S. Preventice Service Task Force. (2021).
https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P
Williams, B., Mancia, G., Spiering, W., Agabiti Rosei, E., Azizi, M., Burnier, M., … &
Desormais, I. (2018). 2018 ESC/ESH Guidelines for the management of arterial hypertension:
The Task Force for the management of arterial hypertension of the European Society of
Cardiology (ESC) and the European Society of Hypertension (ESH). European heart journal,
39(33), 3021-3104.
188.0 pounds
Normal
Thyroid WNL to
palpation Full cervical
ROM
Carotid pulses normal and equal bilaterally; a faint right carotid bruit is
present Normal JVP; no HJR
PMI 5th ICS, medial to MCL
RR, rate 76 normal S1, S2; no
murmurs faint L femoral bruit is
present
Slight barrel
chested Clear to
auscultation
Sk i n / B re as t :
HEENT &
Neck:
C a r d i o va sc u l ar :
Respiratory:
Normal BS
Abdomen soft, nondistended, nontender
throughout No HSM, mass, or abnormal aortic
pulsation
Genitalia normal for stated
age No hernias seen
Normal
bulk
and
tone No
swollen
joints
CNII-XII grossly intact
Reflexes WNL
and symmetrical Normal Abd o men / G a s t r o i n t es t i n a l :
Gen i to ur i
nary:
M u sc u l o s ke l e t a l :
N e u r o l og i c a l :
A lle r g ic /
I m m u n o l o g i c :
No
adenopathy
No bruising
• Lipid Panel o Total Cholesterol = 230
mg/dL o HDL = 45 mg/dL
o LDL = 120 mg/dL
o TG = 175 mg/dL
Lym pha tic /
E n d o c r i n e :
Hemat ologic:
,
I will share a few helpful tips to help with Ihuman.
Regarding the history section: when you type a question the avatar will match it to their questions so just choose what is available. There is no need to ask long in-depth questions. When asking questions follow the acronym LOCATES or OLDCHARTS. I also writedown the important information on paper to help develop an HPI. Once I hit about 15 questions, I click on hint to see what I am missing then continue to ask questions based on what I am missing until I reach 60 questions.
Regarding HPI: I start the sentence by Darius Davis is a 62-year-old African American male who presents to the clinic with…” and then I follow LOCATES. That format turns the information into a PARAGRAPH. I make sure it flows so sometimes the letters (LOCATES) are not in order. I also add any relevant information that directly relates to the chief complaint. For instance: Be detailed …I attached everything concerning him.
Regarding the Management Plan:
*** I did everything in bullets under each title***
Therapeutic/Non-therapeutic Modalities
· Mention all pharmacological and nonpharmacological treatments
· Add “name, dose, frequency, and duration”
Additional Labs and Diagnostic Tests
· Add all necessary tests
· If there are no test needed, then type none needed at this time
Health Promotion
· List all the health promotion of the patient’s age
· For example: breast screening, colonoscopy, and motor vehicle occupant restraints
· FOR RECOMMENDATIONS SEARCH: https://uspreventiveservicestaskforce.org/uspstf/home
Patient Education
· Add information such as letting the patient know how long their symptoms will last
· Make sure it is in depth as if you are verbally teaching the patient
Social Determinants of Health
· Mention some barriers to treatment based on patient age and information
· For example: health care access, prescription and medical coverage, and education.
· SEACH: https://health.gov/healthypeople/priority-areas/social-determinants-health
Consults
· Add if patient needs any consultation on their condition (ex: dermatologist, cardiologist)
Disposition
· Add if patient needs to return to the clinic or seen by a specialist
· Make sure it is time specific
· Put N/A if none
References
Add 3 references that are relevant, timely (less than 5 years), and professional
You can also add references from Heathy People 2030 or USPSTF. BUT YOU STILL NEED THE 3 SCHOLARLY REFERENCES
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