Evidence-based practice consolidates providing high-quality care synchronizing with patients’ preferences in deciding the care pathway (Gradone & Staffileno, 2019). Chest pain is a common complaint in the whole healthcare and can be caused by a vast range of disease conditions – from musculoskeletal disorders to acute and potentially life-threatening conditions like coronary heart disease (Haasenritter et al., 2015). Clinical management of the presenting symptoms can be tendentious. Chest pain is one of the leading causes of a medical emergency (Weber & February 2010). This assignment undertakes the process of evidence-based diagnostic processing of an eighty-year-old gentleman presented to the emergency department with centralized chest pain and associated symptoms.
Verbal explanation on the subject was given and obtained an informed consent for nursing assessment, history collection, and use of all data gathered. General appearance and presenting history
John (pseudo name) is an 80y old gentleman presented to an emergency with chest pain for the last hour that happened while he was sleeping. He woke up with nausea and shortness of breath(SOB) with excessive sweating; He also developed central chest pain with no radiation to neck, shoulder and jaw.
John further explains that he was sleeping as normal and went to bed at the routine time and woken up with difficulty to breath and excessive sweating. He was very nauseous and vomited very little. Nil feeling of hot sensation and there was no loss of consciousness. Pain that developed after was intense sharp and located in the middle of the chest. The pain was there all the time with a score of 4/10 and there were no factors that aggravated the situation but he felt more recently.
John has a habit of walking at least 30 minutes every day and stays fairly active. John denied habits of alcohol consumption and smoking throughout his entire life. John is in a healthy relationship with his wife. John has a daughter who lives locally and 2 sons- one’s in Australia and youngest son in Wellington. John’s eldest son has hypertension, but the other two children are in good health and John acclaims that he has good physical and emotional family support if needed. Both of John’s parents passed away. John’s dad suffered from prostatic cancer for the last 2 years before he had passed away. John’s mum had no medical conditions. John has 2 brothers and a sister and they all are in good health with no issues. John had traveled to the Islands recently. John also used to take St John’s Wart for his low mood in the past.
John is a slim built NZ Pakeha man, normally fit and well with a medical history of Viral myocarditis in the 1980s. John has been having regular angiogram monitoring which is reportedly normal. John daily takes magnesium supplements over the counter. John has a known drug allergy to Statin which causes him myalgia. John also declined any recent medical concerns; nil change in sleep pattern, weight changes, and no altered bowels. John lives with his wife in their own house and they both are retired. John also helps his son in law in his farm. John is financially stable. John is been having healthy homemade balanced meals with occasional dine outs. He also declined to having any unusual food recently.
John had never needed any hospital admissions when he was a child. John could not remember clearly about his immunizations. John could not remember any surgical procedures done to him. John had low mood periods in the past. John used to have flu vaccine yearly and his last tetanus was 2 years ago. John has also been having regular PSA checks and GP follow-ups in related to his prostate screening
Based on the presenting complaints and clinical history gathered, Mr. John had no pre-existing medical conditions that can contribute to the current symptoms. Mr. John was complaining of chest tightness and feeling of central chest heaviness with shortness of breath and extreme diaphoresis together with considering his age and gender it is possible for John to have acute coronary syndrome (American Heart Association, 2019). Acute Coronary syndrome is used to explain the clinical syndromes caused by ST elevation Infarction, non-ST elevation MI and unstable angina (Bickley, 2017).
John is suffering from shortness of breath on exertion, also noticed tachypnea with a sudden onset of chest pain associated with moderate diaphoresis John could be at risk of pulmonary embolism (March & Oji, O, DNP, APRN, FNP-BC, 2018). Studies say Pulmonary Embolism(PE) could be a life-threatening condition and it occurs at a rate of one in every 3500 New Zealanders approximately (southern cross, 2019). Considering the risk of Pulmonary embolism a complete medical assessment with some diagnostic blood tests and imaging studies are needed for further confirmation(March & Oji, O, DNP, APRN, FNP-BC, 2018).
A pericardial cyst is another diagnostic consideration. Symptoms of Pericardial cyst are pleuritic chest pain associated with dyspnoea. Chances of pericardial cyst have to be considered to avoid the occurrence of life-threatening situations (Kraus & Hoffman, 2019).
A complete physical examination ‘head to toe assessment’ is needed in conjunction with all of the presenting symptoms and that will be able to discover all physiological and psychological abnormalities (Smith, N, RN, MSN, CNP & Balderrama, D, RN, MSCIS, 2017). Taking into account John with no previous medical condition that can contribute to the current manifesting symptoms a thorough examination was conducted concentrated on cardiovascular and respiratory symptoms (Hoffman, Bickley, & Szilagyi, 2017).
John was alert and oriented and Glass glow Coma Scale score was 15/15. On examination John was slightly tachycardic with heart rate (HR) of 95 beats per minute and his blood pressure was 150/90millimeters of mercury. Orthostatic blood pressure was also monitored to rule out postural hypotension which could cause angina in older adults (Hypotension.2013). John had no postural drop with a standing blood pressure of 145/92millimeters of mercury. John’s apical heart rate and radial pulse rate had been consistent. John was saturating 95%on room air with a respiratory rate (RR) of 20 breathes per minute. John was afebrile and his temperature was 36.5 degrees Celsius. John had a constant pain score of 4/10. John’s random blood sugar was 6.5 millimole per liter. John was 176 centimeters high with a bodyweight of 70 kilograms. John has a body mass index of 22.6 which is a healthy weight.
John had been warm to touch peripherally and has maintained a pink color. There was no sign of cyanosis and clubbing on his nail beds. John had dark palmer creases and no noticeable jaundice was present. John had been sweating profusely mostly on his upper body. John had been using glasses and his hearing was normal. John maintained good nasal patency. John had no enlarged lymph nodes and his trachea is centrally located. John had no evidence of puffiness on his face and eyelids. John was well perfused with the capillary return of 2 seconds.
John was lying on the bed with a head elevation of 45 degrees and verbally ensured that John is comfortable to proceed with a further physical examination. On inspection, John’s chest movements were symmetrical bilaterally and there was no muscle wastage noticed. John was able to deliver full sentences without stopping. John’s anterior-posterior diameter was measuring normal. John’s posterior chest expansion was symmetrical. John had no palpable axillary lymph nodes. John’s spinous process was non-tender on palpation, and there was no obvious tenderness on the posterior and lateral thorax. On percussion, John had good resonant sounds anteriorly, posteriorly, and laterally. Mild wheeze was present on the posterior lower lobes on auscultation.
John had been assisted in lying position with the head elevated at 45 degrees and verbally ensured that he is comfortable for further examination. Auscultated John’s anterior breath sounds and nil wheezes noticed. John’s lower limbs were warm to touch and nil edema was present on examination and his calf muscles were soft and non-tender. John had strong peripheral pulses and they were symmetrical bilaterally. On inspection of john’s anterior chest, nil noticeable scars or deformities were present. The point of maximum impulse was clearly visible. Palpation of the precordium revealed the absence of hives and thrills. Audible murmurs existed on auscultation over the mitral and tricuspid areas. Carotid pulses were of standard strength on auscultation and palpation. John’s Jugular Venous Pressure (JVP) measurement was 5cm and it’s above the normal range of 0-3cm (DeVesty, G, BSN, MLS & Caple, C, RN, BSN, MSHS, 2019).
John had a soft abdomen with normal findings on inspection and percussion. John had no changes in his bowel habits and had normal bowel sounds. John reported that he had no concerns with his genitourinary system and was reluctant to do the examination. John had normal strength in all the four limbs and there was a good range of motion. John was well behaved with good spirits and was thinking appropriately. John had declined any memory issues and he had balanced gait. There were no neurological concerns alerting John.
Though John had been presented with pleuritic chest pain and SOB, there was no increased pain and John’s RR remained 20breathes/minute throughout the clinical examination. Chances of John Having pulmonary embolism was at low risk as per Well’s criteria (Dorner, Yun, Kwon, Habboushe, & Raja, 2019). Considering the fact of John with a low risk of PE, a biomarker of D-Dimer has to be tested. An increased rate of D-dimer is used to identify the existence of clots in the blood and that indicates the presence of many inflammatory conditions where plasma performs fibrinolytic action (Van Leeuwen & Bladh, 2015).
Literature reviews that the existence of a pericardial cyst is a rare condition but symptomatic presentation mostly resembles pulmonary embolism and acute coronary syndrome (Sallade, Kraus, & Hoffman, 2019).Chances of pericardial cysts have to be ruled out to avoid life-threatening conditions such as tamponade and cardiac arrest (Patel, Park, Michaels, Rosen, & Kort, 2004). The occurrence of the pericardial cyst can be rarely identified on a chest x-ray and hence recommended to perform a two dimensional Echo cardiograph(Sallade, Kraus, & Hoffman, 2019).
John had a constant sharp pain with heaviness in his chest associated with distended JVP. Audible heart murmurs were present with positive changes in John’s Electrocardiograph (ECG). John also reported of having epigastric discomfort and mild nausea. These symptoms clearly exhibit of John could be possibly having Acute Coronary Syndrome (Avital, O, RN, BSN, MBA & Oji, O, DNP, APRN, FNP-BC, 2018). Possibility of John having ACS alerted to perform more diagnostic tests.
John was lying comfortably with close monitoring, meanwhile, blood was sent to the laboratory for complete blood count(CBC),biochemistry tests, D-dimer, troponin and cardiac markers(Avital, O, RN, BSN, MBA & Oji, O, DNP, APRN, FNP-BC, 2018). Blood test results can indicate risk stratification. An Electrocardiograph (ECG) was done since it is the most relevant test that can record cardiac arrhythmias (NZ heart foundation,2019) followed by echocardiography. Diagnostic erect x-ray imaging was also included to rule out the diagnosis.
Troponin: sensitivity indicates the specificity of damage to cardiac muscles(Cardiac troponin.2019).Highly sensible TroponinT has been recommended since it can easily lead to the diagnostic consideration of myocardial Infarct that eventually can help to reduce mortality and providing effective care(Aldous, Richards, Cullen, Troughton, & Than, 2012). Studies illustrate that not all of the chest pain in conjunction with elevated troponin level could lead to ACS(Amjad, Ali, Bashir, Ali, & Azam, 2014), but also consider differential diagnostic conditions such as aortic dissection, pericarditis, severe heart failure, and Pulmonary Embolism.
Full blood counts: Anemia from any source can lead to chest pain and shortness of breath. Findings suggest that anemia and heart failure are the risk factors for older adults presented with Myocardial Infractions (Tisminetzky et al., 2019). Moderate to severe anemia can reduce cardiac perfusion and lead to Ischemic Heart disease. White blood count indicates the measure of Inflammation. High Sensitive C reactive proteins had also been tested and the value can lead to predicting myocardial dysfunction that occurs after acute coronary syndrome (Tisminetzky et al., 2019).
Serum electrolytes: Urea and electrolyte levels in the blood are routinely analyzed to exclude the possibility of abnormal blood chemistry and kidney function (Tisminetzky et al., 2019).Serum potassium level has to be monitored as an altered level could cause cardiac arrhythmias.
Serum Cholesterol: screening of Cholesterol levels is also a key point as hypercholesterolemia is a predominant factor often seen in cardiovascular diseases.
D-Dimer assays: A highly sensitive test used to detects the presence of Venous Thrombo Embolism and PE. This is not considered as a standard test in chest pain but to exclude PE.
Electrocardiogram (ECG): ECG is the baseline investigation for anyone suspected of cardiac diseases. Signs of ischemia, Infarcts and arrhythmia could be identified on ECG. Analyzing ECGs are crucial because management of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) is different.
Echo Cardiograph: used as a diagnostic test to monitor the structure and function of the heart (Ryding, 2013).
Erect Chest Radiograph: chest X-ray is considered as a standard diagnostic test to exclude aortic pathology and pneumothorax (Krombach, Mahnken, & Telger, 2018).
Computed tomography Angiography: is considered as a second-line investigation to rule out cardiac diseases due to cost-effectiveness (Carrabba et al., 2019).CT Coronary angiography found to be of minimal effect in predicting ACS in patients of low-risk category.
John’s laboratory findings were analyzed and full blood count results were unremarkable. John had a slightly elevated lipid profile and Serum Creatinine was 124 against a normal range of less than 105umol/L. Simultaneously John’s electrolyte reports were within the normal range. Series of Troponin T markers were 75 and 139ng/L. John had a negative D-dimer result. John’s C-reactive protein results stayed within normal limits.ECG revealed normal sinus rhythm reporting first-degree Atrioventricular block with T wave inversion in Lead 3.Echo Cardiogram findings revealed John with normal Right and Left ventricular size and function. Nil anatomical abnormalities were discovered but identified mild aortic regurgitation. John’s chest x-ray reported normal except for degenerative changes in the thoracic spine.
Based on the physical examination, clinical assessment, and diagnostic test reports chances for John having pulmonary Embolism could be minimized (March & Oji, O, DNP, APRN, FNP-BC, 2018).A negative high sensitivity D-dimer test effectively excludes the possibility of PE and it leads to the consideration of presenting symptoms that would be more likely of cardiac origin(Cooper, Timmis, & Skinner, 2010).
Pericardial cysts are rare mediastinal cysts which are mostly a congenital condition but can be acquired and are more often detected by the abnormalities on X-ray(Patel, Park, Michaels, Rosen, & Kort, 2004). Studies illustrate two-dimensional echocardiography can identify the presence of pericardial cysts which might be associated with life-threatening conditions like cardiac tamponade(Patel, Park, Michaels, Rosen, & Kort, 2004). John had a completely normal chest x-ray associated with aging degenerations. John’s Echo cardiograph completely evicts the possibility of pericardial cysts’ existence.
Evaluation of causes of chest pain includes serial ECG interpretation, testing Cardiac biomarkers -including high sensitivity troponins, D-dimer, chest x-ray, with a complete physical assessment (Banerjee, 2017). Acute Coronary Syndrome defines a group of coronary artery diseases including ST-segment elevated myocardial infarction (STEMI), non-STEMI(NSTEMI), and unstable angina. Based on the symptom presentation and clinical examination the possibility and risk stratification of ACS can be determined (Achar, Kundu, & Norcross, 2005). Coronary artery disease is considered the leading cause of death and old age is a factor that contributes to the poor prognosis of ACS (Dai, Busby-Whitehead, & Alexander, 2016).
Acute Coronary Syndrome is a serious clinical status that domineering the cause of death for nearly half of cardiovascular origin. The majority of patients with ACS exhibits only partially occlusive thrombus and put up with coronary ischemia without ST Elevation (Moe & Wong, 2010). Nearly half of the patients bearing the symptoms of Acute Coronary Syndrome are admitted to hospitals for further management. Ongoing risk stratification is needed for patients admitted to hospitals as it interrelates with prognosis (Bavry & Bhatt, 2009). Risk stratification in patients with STEMI is related to prognosis whereas in patients with NSTEMI risk stratification is used to guide the therapeutic pathway.
The heart score which includes History, ECG, Age, Risk factors, and Troponin T is considered as a quick and reliable tool in predicting the outcome of patients with chest pain (Backus et al., 2013). Heart scoring system is considered more reliable while comparing to TIMI (Thrombolysis In Myocardial Infarction) and GRACE(Global Registry of Acute Coronary Events) scoring (Backus et al., 2013)and guides the clinician to accelerate treatment pathway.
The relevant symptoms presented by John consist of sudden onset of chest pain, constant existence of pain over a prolonged period of time, acute dyspnea, profused sweating, nausea, and vomiting lead to the diagnostic consideration of Acute Coronary Syndrome. John had a heart score of 5 which is considered as a moderate risk recommending hospital admission. John’s ECG revealed first degree AV block that indicates the presence of subtle cardiac conditions considering his advanced age (Nikolaidou, Ghosh, & Clark, 2016).T wave changes noted on ECG refer to the possibility of non-ST elevated myocardial infarction (NSTEMI). John had been hospitalized for further observation and treatment.
This assignment clearly defines a systematic approach of diagnosing Mr. John presented with non-specific chest pain. The diagnostic tests and investigation results were methodologically incorporated in determining the accuracy of disease status. Treatment measures provided focused on patient safety by ensuring close monitoring, symptom relief, and rectifying underlying cause guarantying upgraded standard of life.