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Did you face any challenges, any success? If so, what were they?
I will say this week has been just great. I have achieved many new experiences when it comes to the way of approaching patients and their sicknesses. My preceptor has been helpful to all my needs and questions, giving me the answer to those questions that I may have for specific patients, which sometimes can become a challenge at the time of getting the best treatment there for them. Telehealth was another great way of contacting patients, now with the COVID 19, many of the patients mostly elderly adults feel this is one as one of the best ways to see their providers, without having to expose themselves to the virus. I feel this is a great improvement in the medical field for those that sometimes can have the limitation of coming to the office. I did not feel that had any challenges at least for this past week, all was really smooth, and the patient was easy to handle.
The Assessment of the Patient with details of the Signs and Symptoms, Assessment, Plan of Care, and Possible Differential Diagnosis
Chief Complaint: Retrosternal pain
HPI: A 70-year-old woman is in the office because she has an 8-year history of retrosternal pain. The pain is often present in bed at night and maybe precipitated by bending down, she rates the pain levels 6 out of 10. Occasionally, the pain comes on after eating and on some occasions, it appears to have been precipitated by exercise. The pain has been described as having a burning and a tight quality to it. The pain is not otherwise exacerbated by respiratory movements or position. Also, she reports do not get improvement with any home remedies.
Her past medical history is negative. The patient snores when sick, but no history of sore throats or ear infections were found on her medical history. There is also no prior history of surgery. Her husband had angina and on one occasion she took one of his glyceryl trinitrates tablets. She thinks that this probably helped her pain since it seemed to go off a little faster than usual. She has also bought some indigestion tablets from a local pharmacy and thinks that these probably also helped.
Health assessment: She is 1.62 m (5 ft 4 in) tall and weighs 82 kg, giving her a body mass index of 31.3 (recommended range 20–25)
Physical Examination:
- General appearance She is an alert, interactive female, a little distressed, and well dressed.
- Head: Normocephalic, atraumatic.
- Eyes: She has no eye abnormalities, unremarkable.
- Ears: Her tympanic membranes are clear.
- Neck: Supple, no adenopathy.
- Chest: Lung sounds clear to auscultation without wheezes, crackles.
- Heart: Heart sounds clear, rhythmic, no murmur.
- Abdomen: Unremarkable.
There are no abnormalities to find in the cardiovascular, respiratory, or gastrointestinal systems.
- Chest X-ray AP and lateral are normal.
- Electrocardiogram (ECG) performed. Heart rate 66/min with no change in the ST segments, also show one ventricular ectopic and some T-wave changes in leads I, Vl, V5 and V6
Diagnosis:
- Gastro-esophageal reflux disease with esophagitis K21.0; features in the history make esophageal reflux a likely diagnosis. The character and position of the pain and the relation to lay flat and bending mean is more likely reflux. She is overweight, increasing the likelihood of reflux. The improvement with glyceryl trinitrate and with proprietary antacids is inconclusive. The ECG shows one ventricular ectopic and some T-wave changes in leads I, Vl, V5, and V6 which would be compatible with myocardial ischemia but are not specific.
Differential Diagnosis:
- Mediastinitis J98. 51: Mediastinitis is swelling and irritation of the chest area between the lungs (mediastinum). Mediastinitis usually results from a tear in the esophagus or chest surgery. Patients have severe chest pain, shortness of breath, and fever. A chest x-ray or computed tomography (CT) is needed for diagnosis. Treatment is with antibiotics and sometimes surgery. The Hamman sign (pathognomonic sign) is a crunching sound heard with a stethoscope over the precordium during systole (Voldby et al., 2017).
- Costochondritis M 94: Inflammation of the cartilage of the rib cage. This condition can cause chest pain. Costochondritis pain may get worse when sitting or lying in certain positions, as well as when a person does any physical activity. Chest discomfort and pain may be stabbing, burning, or aching in nature. The ribs most affected are the second to fifth ones (Foley, 2021).
- Hypertrophic cardiomyopathy I 42.2: often goes undiagnosed because many people with the disease have few if any, symptoms and can lead normal lives with no significant problems. For some, it can cause signs and symptoms of hypertrophic cardiomyopathy may include one or more of the following: chest pain, especially during exercise, fainting, especially during or just after exercise or exertion, heart murmur, which a doctor might detect while listening to your heart, the sensation of rapid, fluttering or pounding heartbeats (palpitations), shortness of breath, especially during exercise (Wang, 2018).
Analysis:
Gastroesophageal reflux is a normal physiologic phenomenon experienced intermittently by most patients, particularly after a meal. Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury (esophagitis) (Krishnan et al., 2016). Patients with GERD can exhibit various symptoms, both typical and atypical. Typical symptoms include heartburn, regurgitation, and dysphagia. Atypical symptoms include noncardiac chest pain, asthma, pneumonia, hoarseness, and aspiration (Katzka & Kahrilas, 2020). Patients typically have numerous daily episodes of symptomatic reflux, including pyrosis, water brash or sour taste in the mouth, nighttime coughing or aspiration, pneumonia or pneumonitis, bronchospasm, and laryngitis, and voice changes, including hoarseness.
In view of the long history and the features suggesting esophageal reflux, it would be reasonable to initiate a trial of therapy for esophageal reflux with regular antacid therapy, H2-receptor blockers, or a proton pump inhibitor (omeprazole or lansoprazole). If the pain responds to this form of therapy, then additional actions such as weight loss (she is well above ideal body weight) and raising the head of the bed at night should be added. If doubt remains, a barium swallow should show the tendency to reflux, and a gastroscopy would show evidence of esophagitis (Katzka & Kahrilas, 2020). There is a broad association between the presence of esophageal reflux, evidence of esophagitis at endoscopy and biopsy, and the symptoms of heartburn. However, each can occur independently of the others.
Recording of pH in the esophagus over 24 h can provide additional useful information. It is achieved by passing a small pH-sensitive electrode into the esophagus through the nose. This provides an objective measure of the amount of acid reaching the esophagus and the times when this occurs (Krishnan et al., 2016).
A follow-up appointment was set up for 2 weeks for reassessment and evaluation
What I learned from the Weeks Clinical Experience that can be Beneficial for me as an APN
I have acquired fundamental skills and experience from the clinical field like never before. Perfect handling of patients needs frequent indulges in learning and knowhow to distinguish various health issues and at the same time, learn the detailed procedures supplied in order to administer appropriate prescriptions to patients depending on their specific needs. Clinical experiences have helped me build significant grounds for my career that will help me to become an experienced professional. I feel the clinical experience has no comparison to any other experience you can have as a student while building your career as a professional.
References
Foley Davelaar, C. M. (2021). A clinical review of slipping rib syndrome. Current Sports Medicine Reports, 20(3), 164-168.
https://doi.org/10.1249/jsr.0000000000000821
Katzka, D. A., & Kahrilas, P. J. (2020). Advances in the diagnosis and management of gastroesophageal reflux disease. BMJ, m3786.
https://doi.org/10.1136/bmj.m3786
Krishnan, K., Pandolfino, J. E., & Kahrilas, P. J. (2016). Gastroesophageal reflux disease. Yamada’s Atlas of Gastroenterology, 72-81. https://doi.org/10.1002/9781118512104.ch10
Voldby, N., Folkersen, B. H., & Rasmussen, T. R. (2017). Mediastinitis. Journal of Bronchology & Interventional Pulmonology, 24(1), 75-79. https://doi.org/10.1097/lbr.0000000000000231
Wang, A. (2018). Hypertension and hypertrophic cardiomyopathy. Hypertrophic Cardiomyopathy, 221-230.
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