Mod 3 AdvH Reply

Case study 3

Throat, Respiratory & Cardiovascular Disorders

Additional subjective data

I would utilize open-ended questions to understand more about the patient's complaint and to learn more about the type of chest discomfort and its history. I would, for example, ask whether the pain started suddenly or gradually and how long it lasted. I would inquire if the patient has previously experienced chest pain and whether it recurs during specific periods of the day, such as during physical activity or stressful situations. Determining if the discomfort radiates to the jaw, neck, back, or arms is crucial because this indicates that a cardiovascular problem may be at play. Also, check whether the patient has any complaint of loss of appetite, vomiting, sweating, dizziness, lightheadedness, palpitations, or shortness of breath (Gulati et al., 2021). Although she has lowered her risk of heart disease, I would have additionally looked at her history of cardiovascular conditions, including angina, myocardial infarction, or heart failure. Comorbid conditions such as diabetes, hypertension, and any family history of cardiovascular disease would also be significant. Given that the patient is an elderly, obese woman, pertinent inquiries would center on her physical exercise endurance and any alterations in her functional abilities.

Additional objective data

I would conduct a sufficient physical examination in light of the objective data to look for any cardiovascular or other issues. Additional testing for JVD, peripheral edema, cyanosis, and signs of orthostatic hypotension would be part of the cardiovascular examination. When examining the chest, the first useful test is to palpate the precordium to feel for heaves or to see where the PMI is located, which could be a sign of cardiac enlargement (Gulati et al., 2021). The chest pain may also be caused by cardiac or pulmonary issues. Additionally, a thorough respiratory examination is required. This would entail listening for crackles, wheezing, or diminished breath sounds, which could indicate a pulmonary embolus, pneumonia, or heart failure. As an illustration, I could measure pulse oximetry both at rest and when mobilizing, then look for exertional hypoxia that might be a sign of heart or lung disease that is based overseas. In addition, I would conduct an abdominal examination to feel for dullness in each quadrant, particularly the epigastrium, which could be a sign of peptic ulcer disease or GERD. Finally, to rule out any other neurological cause of chest pain, a baseline neurological test would be conducted.

Diagnostic Exams

I would start by ordering a 12-lead ECG right away to rule out arrhythmias, myocardial ischemia, and any other associated cardiac conditions. Given her history of hypertension and chest discomfort, CK-MB and troponin I or T measurements should be made to look for signs of myocardial necrosis. A CXR might help identify whether the chest pain is due to pulmonary causes, such as pneumonia, pneumothorax, or early heart failure symptoms like cardiomegaly or lung congestion. An echocardiogram would show the heart's LVEF, regional wall motion, valve disease, and structural and functional ability. To diagnose CAD, I would request a stress test or a coronary angiography if the first tests show ischemia. Given that liver disease impacts general physical health, blood tests should be performed to ascertain the patient's liver state because the sclera color appeared rather icteric. A CT pulmonary angiography or the D-dimer test might be relevant if a pulmonary embolism diagnosis is suspected. Incorporating an endoscope or barium test to detect any esophageal disease is possible if the likelihood of gastrointestinal causes, particularly GERD, is highly considered.

Differential diagnosis

Atypical presentation of acute coronary syndrome (ACS), gastroesophageal reflux disease (GERD), and stable angina pectoris are three differential diagnoses to take into account depending on the patient's presenting symptoms (Gulati et al., 2021).

Rationales for each differential diagnosis

Although it is exertional, the primary reason this is regarded as stable angina pectoris is the need for rest to alleviate the chest pain. The diagnosis is consistent with the typical symptoms of angina based on the patient's description of the pain as a burning or aching sensation in the sternum. The patient had a history of obesity and hypertension, two conditions that increase the risk of developing coronary artery disease (CAD), which can cause stable angina. Even though she denied having arm discomfort, it is important to remember that older patients, particularly women, can have angina with atypical symptoms such as fatigue and dyspnea that set them apart from normal ones (Gillen & Goyal, 2022).

Gastroesophageal reflux disease (GERD) is another probable diagnosis because the pain is characterized as burning in the sternum. The patient's overall dental health and other dental caries may be related to certain food habits that exacerbate acid reflux. The absence of pain that intensifies with deep breaths and the knowledge that obesity is a risk factor for GERD allow for the exclusion of pulmonary causes. Particularly in elderly patients, GERD is one of the reasons for noncardiac chest discomfort that can resemble anginal pain (Gillen & Goyal, 2022). Given the absence of symptoms like jaw and arm discomfort that radiate from the chest, the atypical presentation of ACS in this instance should not be disregarded.