Presenting Signs and Symptoms Supported with Evidence Based Citations (Essay Sample)

Student


Date


Instructor


Course


Patient Initial


Unit/ Room#


DOB


Code Status


Height/Weight

5’55”/195 lbs

Allergies


Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

98.7

141bmp

24

92%

185/98

8

History of Present Illness including Admission Diagnosis &
Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

Chief Complaint: Chest Pain and R/O myocardial infarction
A R/O myocardial infarction or heart attack occurs when part of the heart's supply is cut off. This occurs most commonly following the rupture of an atherosclerotic plaque, which is a collection of lipid and white blood cells in the wall of an artery as a result of occlusion of the coronary artery. Left untreated, ischemia can lead to muscle tissue death or infarction of the heart. acute myocardial infarction is most often described as sudden, radiating chest pain that radiates to the left arm or left chest, dizziness, fatigue, and anxiety. Women typically have fewer symptoms than men, especially shortness of breath, indigestion, and fatigue. a substantial proportion of MI, 22-64% have no known symptoms. electrocardiogram, echocardiography, and various blood tests can be used to screen for heart muscle damage The most frequently used biochemical markers are the creatine kinase MB and troponin levels (Hecht et al., 2019). Oxygen and aspirin should be given as treatment for a possible case of acute myocardial infarction. angioplasty or thrombolysis is the usual approach in the treatment of most cases of acute myocardial infarction with an elevation on the tracing. The non-ST elevation MI may be treated with medication, but, if necessary, should be treated with PCI. People with multiple coronary artery blockages may benefit from bypass surgery.
An unifocal myocardial infarction is differentiated into two general categories: (i.e., those based on pathology that affects the whole heart) and multifocal myocardial infarction is determined by pathogenesis. linked to atherosclerosis in a major coronary artery It can be broken down into three sections: anterior, posterior, and lateral Transmural infarcts occur in the whole-thickness of the muscle and are always caused by complete obstruction of the coronary artery supply. an area in the subendocardium, ventricular septum, or papillary muscles. It is especially susceptible to hypoxia, or hypo-perfusion of the subendocardium.
Sudden cardiac death is occasionally goes by the name of a heart attack because it may or not. A cardiac arrest may or may occur instead of a heart attack. Myocardial infarction (MI) is different from this type of heart failure because of impaired pumping of the heart muscle is a possibility, but myocardial damage leading to severe heart failure is almost always present first.
Family History: He is married with 3 children.

Physical Assessment Findings:
General Appearance: in the ER bed with a lot of distress
Cardiovascular: abnormal heart rate and irregular rhythm, chest pain and shortness of breath.
Respiratory: He seems to have issues with his respiration because of the pain in the chest area.
For the patient with chest pain, all relevant information should be given consideration. Not all chest pain is heart-related, and not all people who have a cardiac problems will present with symptomatic chest pain. Chest pain has many possible origins. The common causes of chest pain are cardiac, respiratory, gastrointestinal, and/ This paper will analyze several possible causes of chest pain, and will later focus on cardiovascular, respiratory, and circulatory evaluations in the setting of a patient with a primary complaint of chest pain. a disruption of the blood flow to the heart leads to a myocardial infarction or a heart attack. Patients often experience a painful/tightness in the chest (Hecht et al., 2019). The pain can be felt radiating to the jaw or left arm sometimes. Pain comes on suddenly or develops gradually. Nitroglycerin doesn't help with this kind of pain.
A dissection of the inner layers of the aorta occurs. The pain hits the chest or the back suddenly and is described as sharp, stabbing, or rending in nature Nonopioid painkillers and surgery are required to relieve the pain.
Lung, liver, gallbladder, and digestive tract conditions are the leading causes of pain in the chest. this type of pain is known as abdominal pain that is relieved by antacids, or changes in diet, or pain medication is applied to the epigastrium
It is common to experience chest pain with muscle and cartilage injuries. Costochondritis is an inflammatory condition of the cartilage which may cause pain. bruised or damaged ribs can cause soreness in the chest. Although similar types of pain can be reproduced, this kind of pain is not relieved by nitroglycerin.
Pulmonary embolism (or chest pain) is the underlying cause of blood clots in the lung that causes shortness of breath and pain in the chest. pleurisy, which is an inflammation of the lung's membranes produces a chest condition that worsens when one coughs or inhales In addition to causing chest pain, pulmonary hypertension may also causes shortness of breath, not being able to carry out activities, coughing, and fatigue.

Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),
include dates and rationales supported with Evidence Based Citations

Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(include dates, if not found state so)
Supported with Evidence Based Citations

Diagnostic Procedure: Based on the lab results and findings we concluded that prior medical history of chest pain, cardiovascular risk factors, and previous complaints should be taken into consideration when attempting to determine the etiology of chest pain. Thus far, all but the history of chest pain has been presented in this series. Recognition of symptoms associated with chest pain is crucial for proper diagnosis and treatment.
In the differentiation of chest pain, the length of pain duration helps distinguish between the different types of chest pain. constant or progressive pain, such as after physical activity, is unlikely to be an angina attack. Acute pain that occurs and goes away within one minute is unlikely to be caused by cardiac issues. In contrast, pain from ischemic heart disease can last for periods varying from 5 to 20 minutes, and is alleviated by administration of GTN for one to five minutes or less (Hecht et al., 2019). GTN spray also relieves abdominal pain caused by oesophageal displacement.
There are several different descriptions for ischaemic chest pain, based on the patient's feeling of it. A description of this pressure includes the terms "heavy" and "feeling of indigestination". If the pain is reproduced by palpation, worse on breathing, or when coughing, it is very unlikely to be caused by a venous lesion.
The typical pain that accompanies ischemia ischemic conditions is relieved by rest and general-purpose pain medication. Severe discomfort or pain that is relieved by changes in breathing or by antacids doesn't imply heart disease.
The patient should be questioned about the use of recreational drugs, herbal or OTC medications when diagnosing chest pain.

Past Medical History: HTN, CAD, Hyperlipidemia, Lumbar Discectomy.
HTN or rather high blood pressure is defined as a systolic pressure greater than 140 or diastolic pressure greater than 90 mm Hg on two or three visits. There are two kinds of hypertension: primary (essential) and secondary. the presence of essential hypertension refers to patients, defined as those with hypertension that is not secondary to another underlying condition. Secondary hypertension has a discernable root cause, such as renal aneurysm or polycythemia (Mononen et al., 2020).
Ischemotherolism or atherosclerosis, also known as CAD, is caused by the plaque buildup in the coronary arteries, which decreases the impact of oxidized blood to the heart. Angina and myocardial infarction, are two forms of CAD that are commonly acknowledged as the precursors for a heart attack. Angina is best described as chest pain or discomfort, which can spread throughout the entire muscles is termed angina. A decrease in the amount of oxygen-rich blood to a specific muscle will lead to a heart attack, but blood can be halted for a few minutes without endangering the rest of the body. That comes out to approximately 60,000 deaths per year from CAD in the United States each and every hour (Mononen et al., 2020).
Hyperlipidemia is among the most frequently seen related cardiovascular conditions. The hyperlipidemia pathology can be classified into primary and secondary forms. The metabolic disorders, not the genetic factors...