"Comprehensive Case Study Analysis of Florence Blackman: 49-Year-Old Female with Chest P, Exams of Integrated Case Studies

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"Comprehensive Case Study Analysis of

Florence Blackman: 49-Year-Old Female

with Chest Pain – iHuman Week 7

Assignment for NURS 6512 at Walden

University"

Case Overview

Patient : Florence Blackman, 49-year-old Caucasian female Chief Complaint : Intermittent “squeezing” chest pain for 2 weeks Setting : Outpatient clinic Course Context : Week 7 assignment for NURS 6512 (Advanced Health Assessment) or similar at Walden University Objective : Develop advanced clinical reasoning skills, including history-taking, physical examination, differential diagnosis formulation, and evidence-based management, using the iHuman platform. HPI : Florence Blackman presents with new-onset, intermittent, exertional mid-chest pain described as “squeezing,” radiating to her left arm, rated 6/10 in severity, and associated with dyspnea on exertion. The pain began during a skiing trip in cold weather, was relieved by rest, and did not recur during regular exercise in warmer conditions. Recently, the pain returned during exertion. She denies nausea, vomiting, diaphoresis, palpitations, or syncope. Her medical history includes hypertension (HTN), hyperlipidemia (HLD), and a 20 pack-year smoking history (quit 5 years ago). She has a family history of heart disease (father had myocardial infarction at age 55) and reports a high-stress job as a financial analyst. Medications include lisinopril and atorvastatin.

Expanded History Questions (Multiple-Choice Format)

The iHuman platform requires selecting key history questions to gather pertinent positives and negatives. Below are 20 sample questions with multiple-choice options to simulate the iHuman interface, focusing on chest pain evaluation.

Question 1

How can I help you today? a. I’m feeling fine, just here for a checkup b. I have chest pain c. I’m having trouble breathing d. I have a cough Correct Answer : b Rationale : The chief complaint is chest pain, guiding the focus of the history.

Question 2

What does the pain in your chest feel like? a. Squeezing b. Burning c. Stabbing d. Aching

Correct Answer : a Rationale : The patient describes “squeezing” pain, suggestive of cardiac ischemia.

Question 3

How severe is the pain on a scale of 1–10? a. 1– 2 b. 3– 4 c. 5– 6 d. 7– 10 Correct Answer : c Rationale : The patient rates the pain as 6/10 during exertion, indicating moderate severity.

Question 4

Does anything make the pain better or worse? a. No triggers b. Worsens with exertion, improves with rest c. Worsens with eating d. Worsens with deep breathing Correct Answer : b Rationale : Exertional pain relieved by rest is characteristic of angina.

Question 5

Do you have any other symptoms with the chest pain? a. No other symptoms b. Dyspnea on exertion c. Nausea and vomiting d. Palpitations Correct Answer : b Rationale : Dyspnea on exertion accompanies the chest pain, supporting a cardiac etiology.

Question 6

How long does the chest pain last? a. A few seconds b. 2–5 minutes c. 30 minutes d. Hours Correct Answer : b Rationale : Pain lasting 2–5 minutes, relieved by rest, is consistent with angina.

Do you smoke or have a history of smoking? a. Never smoked b. Quit 5 years ago, 20 pack-years c. Current smoker, 10 cigarettes/day d. Occasional vaping Correct Answer : b Rationale : A 20 pack-year smoking history is a significant cardiovascular risk factor.

Question 12

What medications are you currently taking? a. None b. Lisinopril and atorvastatin c. Aspirin only d. Metformin Correct Answer : b Rationale : Lisinopril (for HTN) and atorvastatin (for HLD) align with her medical history.

Question 13

Do you have any allergies? a. Penicillin b. No allergies c. Sulfa drugs d. Latex Correct Answer : b Rationale : The patient denies allergies, important for medication planning.

Question 14

Have you experienced nausea or vomiting with the chest pain? a. Yes, frequent nausea b. No nausea or vomiting c. Occasional vomiting d. Nausea without vomiting Correct Answer : b Rationale : Absence of nausea/vomiting makes acute MI less likely but does not rule out angina.

Question 15

Do you experience sweating with the chest pain? a. Yes, profuse sweating

b. No sweating c. Mild sweating d. Sweating at rest Correct Answer : b Rationale : Lack of diaphoresis suggests angina rather than acute MI.

Question 16

Have you had any recent changes in your exercise routine? a. No changes b. Increased intensity c. Stopped exercising d. New exercise program Correct Answer : a Rationale : The patient’s regular exercise did not trigger pain in warmer conditions, but exertion in cold weather did, suggesting environmental influence.

Question 17

Do you have a history of acid reflux or heartburn? a. Yes, frequent heartburn b. No acid reflux c. Occasional heartburn d. Recent onset of heartburn Correct Answer : b Rationale : No history of acid reflux reduces the likelihood of GERD as the cause.

Question 18

Have you experienced palpitations with the chest pain? a. Yes, frequent palpitations b. No palpitations c. Occasional palpitations d. Palpitations at rest Correct Answer : b Rationale : Absence of palpitations makes arrhythmia less likely.

Question 19

How would you describe your stress levels? a. Low stress b. High stress due to work

o Auscultate heart: S1, S2 normal, no murmurs, rubs, or gallops. o Palpate peripheral pulses: 2+ bilaterally (radial, femoral, dorsalis pedis).

• Abdomen : o Inspect abdomen: Flat, no distension. o Auscultate bowel sounds: Normal, present in all quadrants. o Palpate abdomen: Soft, non-tender, no organomegaly. o Auscultate abdominal/femoral arteries: No bruits.
• Extremities : o Inspect for edema: None present. o Inspect for cyanosis/clubbing: None present. o Assess skin: Warm, dry, no lesions.
• Neurological : o Assess mental status: Alert and oriented x3. o Assess motor strength: 5/5 bilaterally. o Assess sensation: Intact bilaterally.

Differential Diagnoses

Using the iHuman platform’s ranking system, the differential diagnoses are prioritized based on history and exam findings:

1. Unstable Angina (Leading Diagnosis) : o Pertinent Positives : Exertional squeezing chest pain radiating to left arm, relieved by rest, associated dyspnea, history of HTN, HLD, smoking (20 pack- years), family history of heart disease, high-stress job. o Pertinent Negatives : No nausea, vomiting, diaphoresis, palpitations, or prolonged pain (>20 minutes). o Rationale : The exertional nature, radiation, and relief with rest, combined with cardiovascular risk factors, strongly suggest unstable angina. ACC/AHA guidelines prioritize urgent evaluation for acute coronary syndrome (ACS).
2. Myocardial Infarction (MI) : o Pertinent Positives : Squeezing chest pain, radiation to left arm, cardiovascular risk factors. o Pertinent Negatives : Pain resolves with rest, no diaphoresis or nausea, duration <20 minutes. o Rationale : MI must be ruled out due to risk factors and symptom similarity, but the intermittent nature makes unstable angina more likely.
3. Gastroesophageal Reflux Disease (GERD) : o Pertinent Positives : Chest pain. o Pertinent Negatives : No heartburn, acid taste, or postprandial symptoms; pain not relieved by antacids. o Rationale : GERD is less likely due to the exertional trigger and lack of gastrointestinal symptoms.
4. Costochondritis : o Pertinent Positives : Chest pain.

o Pertinent Negatives : No chest wall tenderness, pain not reproduced by palpation, exertional nature. o Rationale : The absence of localized tenderness and exertional pain makes costochondritis unlikely.

5. Pulmonary Embolism (PE) : o Pertinent Positives : Chest pain, dyspnea. o Pertinent Negatives : No pleuritic pain, no sudden onset, normal SpO2, no risk factors (e.g., recent immobility, surgery). o Rationale : PE is less likely without acute onset or risk factors, but it must be considered due to dyspnea.
6. Aortic Dissection : o Pertinent Positives : Chest pain, hypertension. o Pertinent Negatives : No tearing pain, no sudden onset, no pulse deficits. o Rationale : Aortic dissection is unlikely without characteristic tearing pain or neurological symptoms.

Problem List

1. Intermittent exertional chest pain
2. Dyspnea on exertion
3. Hypertension (BP 140/90 mmHg)
4. Hyperlipidemia outta control
5. History of smoking (20 pack-years, quit 5 years ago)
6. Family history of heart disease (father’s MI at 55)
7. High-stress work environment

Diagnostic Plan

The iHuman platform requires selecting appropriate diagnostic tests. Based on ACC/AHA guidelines for chest pain evaluation, the following tests are indicated:

1. Electrocardiogram (ECG) : o Purpose: Assess for ischemic changes (e.g., ST-segment elevation/depression, T- wave inversion). o Expected Findings: Possible ischemic changes in unstable angina; normal in non- ST-elevation MI.
2. Cardiac Enzymes (Troponin, CK-MB) : o Purpose: Rule out myocardial infarction. o Expected Findings: Normal in unstable angina; elevated in MI.
3. Exercise Stress Test : o Purpose: Evaluate for exercise-induced ischemia, confirming unstable angina. o Expected Findings: ST-segment changes during exertion suggest coronary artery disease.
4. Chest X-Ray :

Hypothetical iHuman Feedback

The iHuman platform provides feedback on history, physical exam, differential diagnoses, and management. Below is a hypothetical feedback summary based on typical iHuman evaluation criteria:

• History-Taking (90/100) : o Strengths : Selected key questions about pain characteristics, triggers, associated symptoms, and cardiovascular risk factors. o Areas for Improvement : Missed questions about recent travel/immobility (PE risk) or specific dietary habits (GERD risk). o Recommendation : Include 1–2 additional questions to rule out less likely differentials.
• Physical Exam (85/100) : o Strengths : Comprehensive cardiac, pulmonary, and abdominal exams. o Areas for Improvement : Did not assess for costochondral tenderness or respiratory effort. o Recommendation : Include chest wall palpation to definitively rule out musculoskeletal causes.
• Differential Diagnoses (95/100) : o Strengths : Correctly prioritized unstable angina and MI; included non-cardiac causes like GERD and PE. o Areas for Improvement : Consider adding anxiety-related chest pain for completeness. o Recommendation : Ensure all plausible diagnoses are ranked with supporting evidence.
• Diagnostic Tests (90/100) : o Strengths : Appropriate selection of ECG, cardiac enzymes, and stress test. o Areas for Improvement : Consider adding D-dimer if PE is higher on differential. o Recommendation : Tailor tests to patient-specific risk factors.
• Management Plan (92/100) : o Strengths : Aligned with ACC/AHA guidelines; included urgent referral, medications, and lifestyle changes. o Areas for Improvement : Specify follow-up test interpretation (e.g., stress test results). o Recommendation : Include patient-centered communication strategies. Overall Score : 90.4/ Comments : Strong clinical reasoning with appropriate prioritization of cardiac etiology. Ensure comprehensive questioning and exam components to rule out all differentials. Excellent use of evidence-based guidelines.

Expert Review and Key Learning Points

This case study emphasizes the critical evaluation of chest pain in a middle-aged female with cardiovascular risk factors. Key takeaways include:

• Systematic History-Taking : Asking OLD CART (Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Radiation, Timing) questions ensures a thorough HPI.
• Focused Physical Exam : Cardiac, pulmonary, and abdominal exams are critical to differentiate cardiac from non-cardiac causes.
• Differential Diagnosis Prioritization : Use risk stratification (e.g., HEART score) to prioritize life-threatening conditions like ACS.
• Evidence-Based Management : ACC/AHA guidelines recommend urgent evaluation, anti-ischemic therapy (e.g., beta-blockers, aspirin), and lifestyle modifications for suspected angina.
• Patient-Centered Care : Address the patient’s high-stress job and provide education on recognizing worsening symptoms. Challenges :
• Distinguishing between stable and unstable angina requires careful history (e.g., new onset, increasing frequency).
• Non-cardiac causes (e.g., GERD, musculoskeletal) can mimic cardiac pain, requiring thorough exclusion.
• iHuman platform navigation requires efficient selection of questions and exam components to maximize score. Hypothetical iHuman Interface Notes :
• History Module : Interactive question bank with options like “What does the pain feel like?” and multiple-choice responses.
• Physical Exam Module : Checkbox interface for selecting vitals, cardiac, pulmonary, etc., with immediate feedback on relevance.
• Differential Diagnosis Module : Drag-and-drop ranking system with rationale input.
• Management Plan Module : Input fields for medications, referrals, and follow-up plans, with guideline-based feedback. Note : Actual screenshots are proprietary and cannot be provided. The above reflects typical iHuman functionality.

Study Tips for Week 7

• Review ACC/AHA Guidelines : Study chest pain evaluation algorithms, including ACS and non-cardiac causes.
• Practice iHuman Cases : Familiarize yourself with the platform’s history, exam, and diagnosis modules using practice cases.
• Understand Risk Factors : Focus on cardiovascular risk factors (HTN, HLD, smoking, family history) and their impact on diagnosis.