Question

A 52-year-old female presents to your office with complaint of heartburn, nausea, and one episode of vomiting this morning. She reports the pain began two hours after eating and is 5/10 on pain scale with 10 being the worst. She has taken four Tums antiacids and one Pepcid without relief. Since vomiting, she reports her esophagus is “on fire” and is pointing to her midsternal area. She thinks she is getting the flu or COVID, feeling feverish and sweaty, with mild shortness of breath. She meant to get her seasonal flu vaccine in October but did not have time. She appears anxious, but in not in acute distress. You last saw the patient 6 months ago for a new patient encounter. At the time the patient had vital signs indicative of prehypertension, fasting blood sugar of 103 indicating prediabetes, and overweight with a BMI of 27.8. She was to engage in lifestyle modifications for 3 months and return to clinic for follow up. Otherwise, her PMH, SH, and FH other than father and mother both alive. Father with history of HTN and dyslipidemia. Mother with history of asthma and allergies. Brother alive with history of HTN. VS today: BP 157/90 Resp 22 O2Sat 97% Pulse 104 Temp 98.8 At this point what are your top three differential diagnoses with rationale? Is there a must-not-miss diagnosis? If so, assuming your clinic has onsite lab, ECG, and xray capability, what tests should be ordered? What findings would you expect that would confirm this diagnosis? For each of your differential diagnoses, what would be the classic clinical presentation (both subjective and objective findings)? Assuming your most plausible diagnosis is the final diagnosis, what is your treatment plan (include nonpharm and pharm with complete prescriptions)?

Answer 1

​​​​​Nursing diagnosis

​​​​​​1. Acute pain on chest related to heartburn as manifested by pain scale reading 5/10 .

2. Impaired tissue perfusion related to high blood viscosity to the cardiac chandra as manifested by blood pressure

3.anxiety related to lack of knowledge about disease condition as manifestd by verbal data and profuse sweating.

investigations

​​​​​​An ECG and X ray chest should be taken to differtiate cardiac issue and reason for chest pain.

We can expect the findings

Like decreased RR interval, short T wave .

On x ray we shall find some slight white patches on the oesophageal region.

Clinical manifestations

Subjective data: pain scale 5/10, (pain)

157/90 mmHg (hypertension)

Sweating ( anxiety)

Objective data : family history of hypertension ,

Verbal report (pain)

Sweating ( anxiety).

Treatment plan

Non pharmacological

• Reassure the client .
• Check the vital signs half hourly
• Provide her comfortable position. Make her comfortably in Fowler's position.
• Check glucometer sugar
• Monitor pulsoximeter oxygen saturation
• Educate her to reduce over weight .
• Teach her deep breathing and coughing exercises.

Pharmacological measures

• Provide antacid - syp. Gelusil 10 ml tid
• Analgesics - tab. P mol as needed sos
• As per her further investigation results can provide her other pharmacological measures.