Week 10: Common Health Conditions with Implications for Women, Part 1

Discussion: Diagnosing and Managing Common Cardiovascular and Neurologic Conditions

MAIN QUESTION POST

Case Study 2

“You are seeing a 63-year-old African American female for a two-week history of intermittent chest pain. The pain varies in intensity and resolves with rest. She does not believe it has increased over time. She is a nonsmoker with a history of hypertension treated with Lisinopril 10 mg once daily. She had an exercise stress test one year ago that was within normal limits. Her physical exam findings are as follows: HR–90, BP–150/92, R–22, O2Sat 98% RA; lungs: clear to auscultation bilaterally; cardiovascular: apical pulse of 90 RRR, no rubs, murmurs, or gallops. Chest wall mildly tender to palpation that reproduces her complaint of pain. Extremities include no clubbing, cyanosis, or edema. The remainder of the exam is within normal limits.”

Diagnosis

Before diagnosing a patient’s problem, through history and assessment is important. Initial assessment involves a thorough history, including chest discomfort and related symptoms as well as risk factors, in order to assess the likelihood of coronary artery disease. The diagnosis for this 63-year-old African American female who is complaining intermittent chest pain varies in intensity and resolves with rest is stable angina. Stable angina is the type of chest pain that often occurs with activity and relieves at rest (Montalescot et al., 2013). It is the result when the heart tends to need more blood and can be the result when the arteries are severely narrowed (Sarbaziha et al., 2012). The new onset of angina suggests obstructive or non-obstructive coronary artery disease (CAD). Diagnosis is dependent upon an abnormal stress test and proof of atherosclerotic plaque greater than 70%; however, 30% of women will have non-obstructive disease.

Differential Diagnosis

The differential diagnosis for this patient are myocardial infraction, costochondritis, and pericarditis.

Myocardial Infraction: The first differential diagnosis for this patient is myocardial infarction. Women are at a greater risk for CAD and therefore myocardial infarctions in women in the age group of 35-79 years old have increased (Tharpe, Farley, & Jordan, 2017). Women can present with vague different symptoms than men such as fatigue, shortness of breath, back pain, and indigestion (Tharpe, Farley, & Jordan, 2017). An electrocardiogram (ECG) is inexpensive and rapid which is used to diagnose an MI or any acute coronary syndrome. I did not pick this as the primary diagnosis because the patient is having a normal heart rate and rhythm, chest discomfort on and off for two weeks, and chest pain relieving with rest.

Costochondritis: The pain of costochondritis is typically localized to one or more of the costochondral or costosternal junctions, with reproduction of the pain on palpation (Douglas, 2018). Costochondritis is diagnosed solely on reproduction of the pain with palpation of the tender areas (Tharpe, Farley, & Jordan, 2017). Costochondritis is known to affect more women than men, and is the result of hard productive cough, repetitive arm movements, or trauma (Flowers, 2017). I did not pick this as the primary diagnosis because the patient’s chest pain resolving with rest, her history does not reveal any trauma or recent cough, and her chest pain resolves with rest.

Pericarditis: The pain of acute pericarditis is typically severe, sudden in onset, and retrosternal or left precordial in location (Tingle, Molina, & Calvert, 2017). The chest pain is often pleuritic, aggravated by supine positioning, and relieved by sitting upright (Tingle, Molina, & Calvert, 2017). A pericardial friction rub may be appreciated on exam which is absent in this patient which rules out the diagnosis. The differentiating test ECG will show diffuse ST-segment elevation and PR-segment depression. I did not pick pericarditis as primary diagnosis because her history did not reveal a pericardial friction rub, no presence of viral or bacterial infection, and her chest discomfort is relieved by rest and has been persistent for two weeks.

Management and Treatment

Cardiovascular disease is the leading cause of death and disability in women but is primarily preventable. “Early identification of women at risk for developing CVD and implementation of early treatment when the disease is present are vital to significantly alter its devastating impact on women” (McSweeney, Pettey, Souder, & Rhoads, 2011, p. 362). The treatment plan will be initiated based on the assessment of risk factors such as diabetes, chronic kidney disease, and hypocholesteremia. Laboratory test needs to be ordered to assess those risk factors. EKG is one of the test to rule out MI by assessing heart function and blood flow. For the patient with normal EKG, stress test may be ordered to know the exercise workload of the heart.

Non-pharmacological treatment includes dietary modification, regular physical exercises and weight management, avoiding alcohol and smoking. Pharmacological treatment is Nitroglycerin 0.4 mg sublingual PRN for rapid relief of acute angina (Tharpe, Farley, & Jordan, 2017). In addition to Lisinopril, beta blockers should be included to manage her blood pressure well and depending upon the lipid panel result Statin and Aspirin 81mg may be ordered to prevent further atherosclerosis and to prevent further cardiac events.

Patient Education

The patient needs to be educated on the followings;

References

• Medication compliant
• Dietary modification
• Weight management
• Regular exercises as tolerated
• Avoiding alcohol, and smoking
• And follow-up on routine basis.

Douglas, B. (2018). Stable Ischemic Heart Disease. Retrieved from https://online.epocrates.com/diseases/14821/Stable-ischemic-heart-disease/Definition

Flowers, L. K. (2017). Costochondritis. Medscape. Retrieved from https://emedicine.medscape.com/article/808554-overview#a6

Montalescot, G., Sechtem, U., & Achenbach, S. (2013). ESC guidelines on the management of stable coronary artery disease. European Heart Journal, 34(38), 2949-3003.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & women’s health (5th ed.). Burlington, MA: Jones & Bartlett Publishers.

Tingle, L. E., Molina, D., & Calvert, C. W. (2017). Acute pericarditis. American Family Physician, 76(10), 1509-14.

McSweeney, J. C., Pettey, C. M., Souder, E., & Rhoads, S. (2011). Disparities in Women’s cardiovascular health. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 40(3), 362-371.

Sarbaziha, R., Sedlak, T., Shufelt, C., Mehta, P. K., & Merz, C. N. B. (2012). Therapy for stable angina in women. Pharmacy and Therapeutics, 37(7), 400–404.