Writing DNP Clinical Case Narratives, Coursework Example

Case Narrative #6

This case narrative focuses on the care I provided for a 55-year-old Caucasian male who was admitted to the emergency department with complaints chest pain. The patient's primary insurance is Blue Cross blue shield. This case incorporates the following doctoral competency objectives.

Objective: 

Objective 4: Use ethical decision-making to promote the well-being of individuals, families, health care professionals in local, national, and international communities

Objective 7: Demonstrate safe, effective assessment, planning, implementation, and evaluation skills in caring for individuals and groups while working in interprofessional collaborative relationships

Objective 5: Utilize evidence-based practice recommendations and professional standards of care to promote health, prevent disease and improve the health status of individuals, families, groups, communities, and populations

DNP role:  I am a certified family nurse practitioner and a DNP resident assessing this patient who is on the Cardiology team. The patient was admitted by prior N.P. 

Setting: Large Urban teaching hospital in NYC

Reason for Encounter: Chest pain

Informant: Patient

History of Present Illness: J.R. is a 55-year-old Caucasian male with h/o HTN, Asthma, and D.M. who presented to the emergency department for chest pain. The patient intermittent chest pain that started two days ago that lasted 30 seconds located around the left chest and shoulder. He describes the pain as dull and non-radiating. The patient endorsed joining the gym recently and has met with a personal trainer three times this week. Today he woke up with a dull pain, to the scale of 4/10, proceeded by a short interval of sharp pain. His wife saw the level of discomfort and advised him to report to the emergency room. Upon arrival to the emergency department, telemetry showed normal sinus rhythm without ischemic changes, Blood pressure 140/80 and heart rate 80 regular rates and rhythm. In E.D., he was given nitroglycerin, which he states the pain helped to some extent. J.R. did not experience chest pain in the past and denied any shortness of breath, nausea, or diaphoresis. Recently also the patient had a muscoskeletal strain based on the fact that he recently began working out. 

Current Medications:

Uses inhaler for asthma

Aspirin 81 mg daily for headaches

Norvasc 10 mg daily

Metformin 500 mg bid

Review of Systems:

Head/Eyes/Ears/Nose/Throat: No vertigo, no headaches. No change in vision. 

Cardiovascular: Recent chest pain not substernal, no shortness of breath, no palpitations, no edema. No syncope

Respiratory: Positive for shortness of breath and moderate cough

Gastrointestinal: Reports recent weight loss and decreased appetite. Denies vomiting, diarrhea, or constipation

Genitourinary: Denies pain or burning with urination, urinary frequency, urinary urgency, unusual vaginal discharge, or vaginal pain.

Physical Examination:

General: Ambulatory, average size male who appears to be his stated age.

Vitals Signs:

Height 6.1 BMI: Normal at 22.1 , Temp. 97.6 Fahrenheit oral, Blood pressure 140/80, heart rate 80 beats/minute, respiratory rate 18 breaths per minute, pulse oximetry 97 % on room air, pain assessment 4 on a scale 1-10 scale

Chest: Respirations even and unlabored. No accessory muscle use. Lungs clear bilaterally throughout. 

Heart: S1,S2 normal without murmur/gallop/rub. Chest pain reproducible with palpation of the left chest

Abdomen: Flat, soft, non-distended. No guarding, no rebound tenderness. No mass palpated. Bowel sounds are active in all four quadrants upon auscultation.

Genitourinary: No lesions or abrasions to the external genitalia.

Neurological: Awake, alert, oriented to person, place, time, and situation.

Impression: S.A. is a 55-year-old Caucasian male with no medical history of  hypertension, diabetes mellitus  and Asthma who presents to the emergency department for intermittent chest pain.

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The differential diagnosis

1. Myocardial Infarction (I21.9)  

 Myocardial infarction is a cardiovascular disorder marked by insufficient blood flow to the heart. The compromised blood flow to the heart is attributed to the blockage of one or more of the heart's arteries. In some instances, the blockage of the arteries termed as plaques can lead to arterial rapture. The major symptoms of myocardial infarction include chest pain that can present with dyspnea or without, diaphoresis, marked by excessive sweating, and nausea (Ibanez et al., 2018). Another indicator of myocardial infarction is the change in heart rate rhythm. The majority of patients diagnosed with myocardial infarction usually have a spike in the heartbeat rate or rhythm. Based on the identified symptoms, Myocardial infarction was ruled out in this patient's case because he presented with a regular heartbeat rate of 80 b/m and had not reported any signs of severe sweating. However, he presented with chest pain which is one of the symptoms of MI hence, the consideration for a differential diagnosis. 

Oxford level of Evidence 1a

2. GERD (K21. 9)

Gastroesophageal reflux disease is a gastrointestinal tract condition that hinders the ring muscle located between the stomach and the esophagus from performing its routine activities. It involves the flow back of stomach contents into the esophagus, which triggers a burning sensation. The muscle involved is the lower esophageal sphincter. It closes upon swallowing food to allow the digestive juices to act on the food. However, the LES fails to perform this action (Gyawali et al., 2018). The immediate symptom of the condition is heartburn since the stomach acids flow back to the esophagus. This often presents like a sharp chest pain that radiates to the neck from the breastbone. The results include a bitter taste in the mouth. Also, the pain can quickly be relieved by rest. Other than that, the other symptoms include nausea and vomiting, difficulties in breathing laryngitis. Based on the patient's indications, GERD was disqualified as the patient's pain was non-radiating. Besides, he never reported any changes in taste and breath. 

Oxford Centre for Evidence-Based Medicine level 2b

3. Pericarditis (130.9)

In the body, there is a thin sac that surrounds the heart. This is referred to as the pericardium membrane and acts as protection and a lubricant for the heart and the surrounding blood vessels. Inflammation of the pericardium membrane is termed pericarditis and often presents with chest pain that worsens with deep breaths, palpations, cough, fever, and painful swallowing (Andreis et al., 2021). The patient is also likely to present with general body weakness and breathing difficulties. However, the patient denies shortness of breath, cough, and fever, which made pericarditis to be considered as a differential diagnosis. 

Oxford Centre for Evidence-Based Medicine level 3a

Plan: 

1. Chest pain

Continue serial cardiac enzymes until the morning and monitor EKGs. Perform an ECHO for potential coronary causes of chest pain (Schmid et al., 2018). Chest discomfort is a significant problem that can lead to drastic consequences. Hence, it was vital to measure the patient's cardiac biomarker. I closely monitored the patient's biomarkers for six hours and recorded no onset of further symptoms

Oxford Centre for Evidence-Based Medicine Level of Evidence 2b

2. The patient has a history of HTN will continue his home medication Norvasc 

Norvasc, or amlodipine, as commonly known, helps in maintaining stable blood pressure. The patient's previous diagnosis indicated that he was hypertensive, which can worsen the patient's current condition if not adequately controlled. Research indicates a close correlation between hypertension and the development and progression of cardiovascular conditions such as ischemic heart disease, which results in insufficient blood flow to the heart muscles (Bundi et al., 2018).  Providing amlodipine, in this case, can help maintain the blood pressure within the normal limits of 120/80 thus preventing patient deterioration. 

Oxford Centre for Evidence-Based Medicine Level of Evidence 4

3. Musculoskeletal strain patient recently started working out. Likely he had a musculoskeletal strain as all tests were negative for cardiac symptoms. Engaging the patient in slow and gradual exercise is likely to facilitate healing if they had had a muscle strain (Smith et al., 2019). However, if the pain persists, I informed the patient to stop the exercises to avoid further deterioration. 

Oxford Centre for Evidence-Based Medicine Level of Evidence 2a

Diagnostics Tests

Labs:

Blood – no protein leak in the blood

Chest X ray – size of lungs normal

Cardiac MRI- Heart function normal

1. An EKG. The rationale for performing the EKG was to provide information if he had EKG changes. 

2. An echocardiogram's rationale was to evaluate wall motion, left ventricular function, and septal thickness to rule out congenital heart defects and cardiomyopathy as the etiology for the arrhythmia (Szekely et al., 2020). 

Oxford Centre for Evidence-Based Medicine Level of Evidence 3b

Laboratory Test Results

Labs	Values	Normal Range
CBC
WBC	4,000	4,000-11,000
RBC	4.72	4.35 to 5.65
HGB	13.4	12-18
HCT	37.8	38-54%
Platelets	205,000	150,000-400,000
Neutrophils	46%	45-75%
Band Neutrophils	5%	0-5%
Sodium	135	135-145
Potassium	4.1	3.5-5.1
Chloride	98	96-106
C02	23	23-29
Glucose	106	70-110
BUN	21	7-20
Creatinine	1.2	0.6-1.2
GFR	>60	90-120
Lactic Acid	1.0	0.5-2.2

SARS COVID- negative

Referrals:

Counseling and Education:

Explained to patient risk and benefits of administering Motrin NSAID

medication	Mode of action	Clinical use	Side effects
Norvasc 10 mg P.O. daily	Relaxing and widening blood vessels	Treating hypertension	Stomach upset, drowsiness, excessive fatigue, and swelling of extremities
Aspirin 81 mg daily P.O.	Inhibits COX-1	Pain reliever and reduces fever	abdominal pain, upset stomach gastrointestinal ulcerations, heartburn, drowsiness,
Metformin 500 mg bid P.O.	inhibition of hepatic gluconeogenesis	Treating type 2 diabetes	Diarrhea, weakness, a metallic taste in the mouth, and nausea and vomiting.
Ibuprofen 400 mg once a day PO	inhibition of the cyclooxygenase enzymes COX-1 and COX-2	relieve pain and inflammation	difficulty breathing or changes in your heart rate (slower or faster), black poo and blood in your vomit, stomach pain, and tinnitus

References

Bundy, J. D., Mills, K. T., Chen, J., Li, C., Greenland, P., & He, J. (2018). Estimating the Association of the 2017 and 2014 Hypertension Guidelines with Cardiovascular Events and Deaths in U.S. Adults: An Analysis of National Data. JAMA cardiology, 3(7), 572–581. https://doi.org/10.1001/jamacardio.2018.1240

Andreis, A., Imazio, M., Casula, M., Avondo, S., & Brucato, A. (2021). Recurrent pericarditis: an update on diagnosis and management. Internal and emergency medicine, 16(3), 551–558. https://doi.org/10.1007/s11739-021-02639-6

Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., ... & Widimský, P. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). European heart journal, 39(2), 119-177. https://doi.org/10.1093/eurheartj/ehx393

Gyawali, C. P., Kahrilas, P. J., Savarino, E., Zerbib, F., Mion, F., Smout, A., Vaezi, M., Sifrim, D., Fox, M. R., Vela, M. F., Tutuian, R., Tack, J., Bredenoord, A. J., Pandolfino, J., & Roman, S. (2018). Modern diagnosis of GERD: the Lyon Consensus. Gut, 67(7), 1351–1362. https://doi.org/10.1136/gutjnl-2017-314722

Schmid, J., Liesinger, L., Birner-Gruenberger, R., Stojakovic, T., Scharnagl, H., Dieplinger, B., Asslaber, M., Radl, R., Beer, M., Polacin, M., Mair, J., Szolar, D., Berghold, A., Quasthoff, S., Binder, J. S., & Rainer, P. P. (2018). Elevated Cardiac Troponin T in Patients With Skeletal Myopathies. Journal of the American College of Cardiology, 71(14), 1540–1549. https://doi.org/10.1016/j.jacc.2018.01.070

Smith, B. E., Hendrick, P., Bateman, M., Holden, S., Littlewood, C., Smith, T. O., & Logan, P. (2019). Musculoskeletal pain and exercise-challenging existing paradigms and introducing new. British journal of sports medicine, 53(14), 907–912. https://doi.org/10.1136/bjsports-2017-098983

Szekely, Y., Lichter, Y., Taieb, P., Banai, A., Hochstadt, A., Merdler, I., Gal Oz, A., Rothschild, E., Baruch, G., Peri, Y., Arbel, Y., & Topilsky, Y. (2020). Spectrum of Cardiac Manifestations in COVID-19: A Systematic Echocardiographic Study. Circulation, 142(4), 342–353. https://doi.org/10.1161/CIRCULATIONAHA.120.047971