iHuman Case Study Analysis: Florence Blackman, 49-Year-Old Female with Chest Pain (Week, Exams of Integrated Case Studies

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iHuman Case Study Analysis: Florence

Blackman, 49-Year-Old Female with Chest

Pain (Week 7)

Case Overview

Florence Blackman, a 49-year-old Caucasian female, presents to an outpatient clinic with a chief complaint of intermittent squeezing chest pain for 2 weeks. This case study is designed to develop advanced clinical reasoning skills, including history-taking, physical examination, differential diagnosis formulation, and evidence-based management, as part of a Week 7 assignment for a course like NURS 6512 (Advanced Health Assessment).

History of Present Illness (HPI)

Florence Blackman reports new-onset, intermittent, exertional “squeezing” mid-chest pain radiating to her left arm, associated with dyspnea on exertion. The pain began during a skiing trip in cold weather, rated 6/10 in severity, and was relieved by rest. The pain subsided when she skied less aggressively and did not recur during her regular exercise in warmer conditions. However, the pain returned recently during exertion. She denies nausea, vomiting, diaphoresis, or palpitations. Her medical history includes hypertension (HTN), hyperlipidemia (HLD), previous smoking (quit 5 years ago, 20 pack-year history), and a family history of heart disease (father had myocardial infarction at age 55). She reports a stressful job as a financial analyst.

Key History Questions

To gather a comprehensive patient history, the following questions are critical:

1. How can I help you today?
2. What does the pain in your chest feel like (squeezing, pressure, crushing, burning, stabbing)? a. Squeezing b. Burning c. Stabbing d. Aching Correct Answer : a Rationale : The patient describes “squeezing” pain, consistent with cardiac etiology like angina.
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.
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 breathing Correct Answer : b Rationale : Exertional pain relieved by rest is characteristic of angina, distinguishing it from non- cardiac causes.

5. Do you have any other symptoms (e.g., shortness of breath, nausea, diaphoresis)? 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, suggesting a cardiac etiology.
6. What are the events surrounding the start of your chest pain?
7. Is there a pattern to your chest pain?
8. Do you have any allergies?
9. Are you taking any OTC or herbal medications?
10. Any recent changes in medications?
11. Do you have a history of heart disease or other medical conditions?
12. Do you have a family history of heart disease?
13. Do you smoke or have a history of smoking?
14. Tell me about your work and stress levels.
15. Tell me about your daily exercise or physical activity.

Physical Examination

A focused physical exam is essential to evaluate potential cardiac and non-cardiac causes of chest pain. Key components include:

• Vitals : o Temperature: Normal (98.6°F) o Pulse: 80 bpm, regular o Blood pressure: 140/90 mmHg (elevated, consistent with HTN) o Respirations: 16 breaths/min o SpO2: 98% on room air
• General Appearance : Well-appearing, no acute distress.
• HEENT : o Inspect eyes, pupils, mouth/pharynx, and nostrils: Normal. o No pallor or cyanosis.
• Neck : o Measure jugular venous pressure (JVP): Normal, no elevation. o Auscultate carotid arteries: No bruits.

o Rationale : The StuCostochondritis is unlikely due to the absence of localized tenderness and exertional pain.

5. Pulmonary Embolism : o Pertinent Positives : Dyspnea, chest pain. o Pertinent Negatives : No pleuritic pain, no sudden onset, normal SpO2, no risk factors like recent immobility. o Rationale : Pulmonary embolism is less likely without acute onset or risk factors like recent travel or surgery.

Problem List

1. Intermittent exertional chest pain
2. Dyspnea on exertion
3. Hypertension
4. Hyperlipidemia
5. History of smoking (20 pack-years, quit 5 years ago)
6. Family history of heart disease
7. Stressful work environment

Diagnostic Plan

To confirm the diagnosis and rule out life-threatening conditions, the following tests are recommended:

1. Electrocardiogram (ECG) : To assess for ischemic changes (e.g., ST-segment changes, Q waves).
2. Cardiac Enzymes (Troponin, CK-MB) : To rule out myocardial infarction.
3. Stress Test : To evaluate for exercise-induced ischemia, confirming unstable angina.
4. Chest X-Ray : To rule out pulmonary causes (e.g., pneumothorax).
5. Lipid Profile : To assess hyperlipidemia control.
6. Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) : To evaluate overall health and rule out anemia or electrolyte imbalances.

Management Plan

1. Immediate Management : o Administer aspirin 325 mg (chewable) to reduce thrombotic risk. o Sublingual nitroglycerin 0.4 mg every 5 minutes (up to 3 doses) if pain persists. o Refer to the emergency department for urgent evaluation due to suspected unstable angina.
2. Medications : o Continue antihypertensive and lipid-lowering medications (e.g., lisinopril, atorvastatin). o Consider beta-blockers (e.g., metoprolol) to reduce myocardial oxygen demand. o Initiate low-dose aspirin (81 mg daily) for secondary prevention.

3. Lifestyle Modifications : o Stress management: Recommend mindfulness or counseling for high-stress job. o Exercise: Moderate aerobic exercise (e.g., 30 minutes most days) once cleared by cardiology. o Diet: Heart-healthy diet (low saturated fat, high fiber, fruits, and vegetables). o Smoking cessation counseling: Reinforce continued abstinence.
4. Referral : o Cardiology referral for stress testing and possible coronary angiography. o Consider referral to a stress management program.
5. Patient Education : o Educate on recognizing cardiac symptoms (e.g., prolonged chest pain, diaphoresis) and seeking immediate care. o Discuss the importance of medication adherence and follow-up.
6. Follow-Up : o Schedule a follow-up in 1–2 weeks to review test results and adjust treatment. o Monitor blood pressure and lipid levels regularly.

Expert Feedback and Analysis

This case study emphasizes the importance of a systematic approach to chest pain in a middle- aged patient with cardiovascular risk factors. The iHuman platform challenges students to:

• Conduct a Comprehensive History : Asking targeted questions about pain characteristics, triggers, and associated symptoms is critical to narrowing the differential.
• Perform a Focused Physical Exam : Vitals, cardiac, pulmonary, and abdominal exams help rule out non-cardiac causes.
• Formulate a Differential Diagnosis : Prioritizing life-threatening conditions (e.g., unstable angina, MI) is essential, given the patient’s risk factors.
• Develop an Evidence-Based Plan : Urgent referral, diagnostic testing, and guideline- directed therapy align with ACC/AHA recommendations for suspected acute coronary syndrome.
• Documentation : Clear, concise documentation of findings, differential diagnoses, and the plan is crucial for clinical practice. Key Learning Points :
• Exertional chest pain with radiation and dyspnea is highly suggestive of cardiac ischemia, especially in patients with HTN, HLD, and smoking history.
• Unstable angina requires urgent evaluation to prevent progression to MI.
• Non-cardiac causes (e.g., GERD, costochondritis) must be considered but are less likely given the clinical presentation.
• The iHuman platform simulates real-world clinical decision-making, reinforcing the importance of evidence-based guidelines (e.g., ACC/AHA for chest pain management). Potential Challenges :