Name Section Week 7 Shadow Health Digital Clinical Ex 456926

Namesectionweek 7shadow Health Digital Clinical Experience Focused E

Include a comprehensive documentation of a clinical case focusing on chest pain, covering subjective and objective data, assessment, and differential diagnoses. The subjective data should well-organize patient-reported information, including chief complaint, detailed history of present illness, medications, allergies, past medical and surgical history, reproductive and social history, immunizations, family history, and review of systems pertinent to chest pain. The objective data should describe physical exam findings, including vital signs, general appearance, and examination of relevant systems, avoiding vague terms like "WNL" and instead providing detailed descriptions.

Make sure to include relevant diagnostic tests or labs that support your differential diagnoses, and list your primary and supporting diagnoses with evidence-based rationale. Incorporate previous diagnoses and note whether they are controlled or uncontrolled, providing a holistic approach to the patient's care with appropriate medical reasoning.

Paper For Above instruction

Introduction

Chest pain remains a significant clinical presentation that warrants thorough evaluation due to its association with potentially life-threatening conditions such as myocardial infarction, pulmonary embolism, or aortic dissection. A meticulous approach to collecting subjective and objective data helps clinicians formulate accurate diagnoses and appropriate treatment plans. This paper will detail a case scenario involving chest pain, illustrating data collection, clinical assessment, and differential diagnosis considerations grounded in evidence-based practice.

Subjective Data

The patient is a 55-year-old Caucasian male presenting with chest pain. The chief complaint is chest discomfort described as a pressing sensation located substernally. The pain began approximately two hours before the visit, initially dull and mild but progressively intensified, radiating to the left arm and jaw. The patient reports associated symptoms of shortness of breath, diaphoresis, and nausea. He states that the pain worsens with exertion and improves with rest. The patient admits to a history of hypertension, hyperlipidemia, and smoking one pack per day for 30 years. He reports taking aspirin 81 mg daily, atorvastatin 20 mg once daily, and occasionally using over-the-counter ibuprofen for musculoskeletal pain. He has no known drug allergies. His past surgical history includes a coronary artery stent placement five years ago. The patient’s family history reveals a father with a myocardial infarction at age 60. Reproductive history is not applicable. Social history indicates moderate alcohol intake and occasional social smoking but no illicit drug use. Immunizations include recent influenza and pneumococcal vaccines. Review of systems reveals no recent weight loss, fevers, or weakness but confirms chest heaviness and dyspnea. No neurological, gastrointestinal, muscular, or psychiatric symptoms are reported, other than the current chest pain and associated symptoms.

Objective Data

The physical examination reveals vital signs: blood pressure 142/88 mm Hg, heart rate 98 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F, oxygen saturation 96% on room air, BMI 28 kg/m². The patient appears anxious but is alert and oriented. General inspection shows no distress at rest, mild diaphoresis, and an anxious facial expression. Cardiac examination indicates a regular rhythm with no murmurs, rubs, or gallops. The chest wall is symmetrical with clear auscultation—bilateral breath sounds are normal without wheezes or crackles. Lung examination does not reveal rales or dullness. Abdominal, musculoskeletal, neurological, and skin assessments show no abnormalities relevant to chest pain. No edema or cyanosis is observed in extremities. Vital findings and physical examination findings suggest a probable cardiac etiology for the chest pain, warranting further diagnostic testing.

Diagnostic Tests and Labs

Electrocardiogram (ECG) shows ST-segment depressions in leads V5 and V6, which are indicative of ischemia. Cardiac enzymes, including troponin I, are elevated, supporting the diagnosis of acute coronary syndrome (ACS). A chest X-ray appears clear, ruling out pulmonary causes like pneumothorax or pneumonia. Lipid profile confirms hyperlipidemia. Additional tests such as echocardiography and coronary angiography are recommended to evaluate cardiac function and coronary artery status respectively. Laboratory assessments include complete blood count (CBC), metabolic panel, and coagulation profile. These results aid in identifying the severity of the presentation and guide management.

Assessment and Differential Diagnoses

The primary diagnosis for this patient is Acute Coronary Syndrome, specifically Non-ST Elevation Myocardial Infarction (NSTEMI). Supporting evidence includes characteristic chest pain, risk factors (age, smoking, hypertension, hyperlipidemia), ECG changes, and elevated troponin levels. The differential diagnoses include:

• Although chest pain can mimic this condition, absence of pulse deficits, mediastinal widening, or severe tearing sensations makes this less likely.
• Symptoms include chest pain and dyspnea, but absence of hypoxia, tachypnea, or leg swelling makes this diagnosis less probable in this case.
• Usually presents with sharp, localized chest pain that worsens with respirations, without ECG changes or elevated cardiac enzymes.
• Can mimic cardiac chest pain but lacks associated risk factors and characteristic ECG or troponin elevation.

Other considerations include musculoskeletal causes or anxiety, although these are less likely given the clinical data. The holistic management approach involves addressing modifiable risk factors, initiating appropriate pharmacotherapy, and planning invasive procedures if indicated.

Conclusion

Effective management of chest pain hinges on prompt, detailed assessment incorporating patient history, physical examination, and targeted diagnostics. Recognizing the pattern of symptoms, risk factors, and clinical findings allows for accurate differential diagnosis, early intervention, and improved patient outcomes. Continuing education and adherence to evidence-based guidelines are essential in managing acute coronary syndromes and their mimics.

References

• Bayés-Genís, A., et al. (2021). Acute Coronary Syndrome. In C. F. Dung et al. (Eds.), Harrison's Principles of Internal Medicine (20th ed.). McGraw-Hill Education.
• Amsterdam, E. A., et al. (2014). 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes. Journal of the American College of Cardiology, 64(24), e139–e228.
• Thygesen, K., et al. (2018). Fourth universal definition of myocardial infarction. Journal of the American College of Cardiology, 72(18), 2231-2264.
• Hirsch, G. A., & Krumholz, H. M. (2017). Acute Coronary Syndrome. UpToDate.https://www.uptodate.com
• Roffi, M., et al. (2015). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal, 37(3), 267–315.
• Jneid, H., et al. (2017). 2017 AHA/ACC clinical performance and quality measures for adult patients with acute myocardial infarction. Journal of the American College of Cardiology, 70(14), 1755–1774.
• O'Gara, P. T., et al. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Journal of the American College of Cardiology, 61(4), e78–e140.
• Cannon, C. P., et al. (2019). Management of acute coronary syndromes. Harrison's Principles of Internal Medicine. McGraw Hill Education.
• Shah, S. J., et al. (2020). Chest Pain and Coronary Artery Disease. Clinical Cardiology, 43(2), 107–115.
• Fihn, S. D., et al. (2012). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. Circulation, 126(25), e354–e471.