Free Nursing Essays - Theoretical And Analytical Processes That Underpin The Various Decision Making Processes
Management Of A Patient: A case study
Introduction
In this essay we are considering the case management of a patient. We will consider this both from the clinical and management aspects of the case and also from the point of view of the theoretical and analytical processes that underpin the various decision making processes that are involved in finally arriving at, and subsequently delivering, an appropriate treatment plan. (Wilkerson et al 1996)
In order to make the appropriate mental adjustment, we shall refer to the patient as Mrs Singh which helps us to consider her as a human being rather than simply just another case to be considered. (Alavi 1995)
The clinical details are set out in Appendix A.
My knowledge of the patient
When Mrs Singh came into the surgery she was already known to me from previous visits. I knew her to have Type II diabetes mellitus and moderate hypertension. She has a poor command of English and her son often accompanies her to help with any translation. He was with her on this occasion.
From my past dealings with of her, I knew that she tended to be anxious (almost to the point of hypochondriasis) and had a marked tendency to overstate her symptoms. (Richards T. 1999)
I also knew, from my dealings with the rest of her (large) family that her husband (in common with many Asian men) was extremely dominant and autocratic, and tended to try to control every aspect of her life. She found this very difficult to handle, but felt that she had to keep up appearances and put a brave face on things. This led to great personal stress and difficulty between them in private. (Barry et al 2000)
The relevant points in the history on this occasion are:
- Chest pain of short duration
- Associated with sweating, dyspnoea and radiation
- Intermittent for four days
- Not eased by antacids
- Aggravated by meals, cold winds and exertion
Models for diagnostic decision making
There are a number of different models we can use for clinical decision making (Glasgow, N 1997) which have a rational basis. One of the most commonly used is the one espoused by Barrows & Pickell (1991)
In broad terms the major stages to be assimilated are:-
- 1) Hypothesis generation (differential diagnosis)
- 2) Enquiry strategy (subjective and objective database)
- 3) Data analysis
- 4) Problem synthesis (ruling in or out possible diagnoses)
- 5) Diagnosis and treatment decision making
We shall shortly apply this rationale to Mrs Singh.
Before we consider her case in detail, we should note that Barrows & Pickell make a number of explanatory observations
A diagnostic decision must be made before you treat. The physician judges the probability of a particular diagnosis then chooses an action
Strategic enquiry results in further patient information, data analysis and problem synthesis. The Process concludes with a probable diagnosis and treatment plan. The plan is developed with client co-operation through empowerment and education. The management or resolution of the problem depends on the consequences of this collaboration.
This latter point is certainly significant in Mrs Singh's case. It has already been demonstrated with her management of Type II diabetes mellitus. She regularly tests her blood sugar levels and adjusts her glucose intake accordingly. (Norris et al 2001)
This process has been established mainly through her empowerment and education. She understands the principles involved and is now quite capable of manipulating her own diet. She appreciates the consequences of poor glycaemic control and takes responsibility for keeping her HbA1 levels within acceptable limits. (Marinker M.1997)
Discussion of the case
Mrs Singh presented at the surgery having made an urgent appointment. She appeared neatly and smartly dressed in a sari and jewellery. She was brought by her son, who often accompanied her for translation purposes.
Her demeanour
She came into the surgery quickly and was clearly agitated, concerned and worried. The short walk from the waiting room had left her markedly breathless and she sat down heavily. It took her about three minutes before she was able to breathe without effort. It was noticeable that breathing gave her distress. She did not sit still and was constantly moving, as if to try to find a comfortable position. She did not make eye contact with me unless it was to reinforce the fact that a symptom was particularly intense. Her answers were mostly directed at her son to translate. (Martyn. C 1999)
Her presenting history
Her main presenting complaint was chest pain of short duration. She had been having bouts of pain like this for about 4 days. She pointed to her breast bone when indicating the site of the pain. It was clearly severe, as she shut her eyes and winced as she described it. She volunteered that it radiated to jaw, neck and shoulder and was associated with sweating and sudden breathlessness.
She told me that she had thought that it was indigestion and had been taking antacids with no effect. She had originally thought this because it was typically worse a short while after she had eaten. She also told me that it was worse when she had been out in the garden doing some physical work and where the wind was cold. When the pain was bad, she lay down on her bed and the pain subsided.
Initial hypothesis generation
On the basis of her history and my initial observations there are a number of different differential diagnostic hypotheses to formulate and then test. These are presented in descending order of probability.
Myocardial Ischaemia - The recurrent and severe retrosternal chest pain is very suggestive of myocardial ischaemia. This hypothesis is strengthened by an associated dyspnoea, radiation to the jaw, neck and shoulder. It is further strengthened by the fact that it is exacerbated by exertion (especially in the cold) and eases with rest. A history of hypertension and Type II diabetes mellitus (Nathan 1998) increase the likelihood of this possible diagnosis. (Maynard et al 2000)
Myocardial infarction is also a possibility to consider although a four day history makes it less likely, as does the fact that the pain subsides spontaneously on rest. Sweating is a factor the strengthens this possible diagnosis (Maynard et al 2000)
Hiatus hernia and acid reflux. The fact that Mrs Singh has a BMI in excess of 40 is a significant supporting factor for this diagnosis,( Després et al 2001), as is the fact that these symptoms are exacerbated by eating. The fact that the pain did not respond to antacids does not exclude the diagnosis as acid reflux can prove to be very resistant to antacids when the symptoms have progressed to a severe level. One would normally expect the pain associated with hiatus hernia and acid reflux to be exacerbated by lying down. This is not the case with Mrs Singh.
Cholecyctitis/ cholelithiasis. Mrs Singh is obese and over 40 which puts her in the primary at risk group for this condition. The fact that her symptoms are aggravated by eating, are not relieved by antacids and exacerbated by work in the garden (bending) are also consistent with this diagnosis. Sweating is another contributory diagnostic feature. The site of the pain is consistent with (but not typical of ) cholecystitis. Pain typically associated with cholecystitis will radiate but classically this is to the right shoulder tip. (Indar et al 2002)
Gastric ulceration. This is a possible diagnosis (and is part of the spectrum of the hyperacidity related diseases). Her Asian ethnicity and the fact that she has been a smoker are both significant risk factors for gastric ulceration. Her belief that the pain was indigestion supports the diagnosis and the fact that she did not respond to antacids does not negate the diagnosis. The pain described is not typical. Such pain can be retrosternal but is more typically also felt in the epigastrium and occasionally in the back.
Congestive cardiac failure. This has to be considered in patients who present with exercise induced dyspnoea. It is not particularly likely (as a primary diagnosis) in this case. Mrs Singh is known to be hypertensive and on Atenolol (both factors that can predispose to congestive cardiac failure). (Britten et al 2000), Classical heart failure however, is made worse by lying down, tends to be more chronic and seldom is associated with this type of pain (as a primary diagnosis)
Hysteria/hypochondriasis. Given Mrs Singh's emotional problems and stresses at home, one should also consider the possibility of a functional overlay. It would be unusual for all these symptoms to be totally due to this type of condition, but we should be alert to the fact that Mrs Singh's emotional state may well help to exaggerate and theatricalise her symptoms and make an objective evaluation more difficult. (Martyn 1999)
Tietzer's syndrome. An occasional cause of episodic retrosternal chest pain. It can be associated with shallow breathing (but not true dyspnoea) (Maynard et al 2000)
Muscle spasm. A possible diagnosis with a muscle strain being brought on in an overweight lady when working in the garden. The pain is not typical, but is relieved by lying down and is not influenced by antacids.
Enquiry strategy
Clearly, with so many possible differential diagnoses apparent after the initial presentation, we must begin to narrow down the field by trying to eliminate some of the less likely contenders.
We have listed the various diagnoses in order of probability on the basis of the evidence that we have so far. A selection of carefully judged questions should help to narrow this down further still.
We will consider each possible diagnosis in turn and consider the type of questions that may be appropriate to help us rationalise the list further.
Myocardial ischaemia. It would be useful to know if Mrs Singh had suffered from other commonly associated symptoms such as palpitations, syncope, fainting bouts - particularly when standing up (postural hypotension), cold periphery, reduced exercise tolerance and increasing levels of dyspnoea.
It would also be useful to know if her HbA1 levels had been abnormal lately or whether, for any reason, she had decided to increase her dose of Atenolol. (Maynard et al 2000)
If any of these factors were positive, it would add strength to the diagnosis of myocardial ischaemia.
Myocardial infarction. The diagnosis would be strengthened by the positive demonstration of syncope, palpitations, dramatic increase in dyspnoea (particularly when lying down, blue extremities, perspiration around the lips, postural hypotension and crescendo levels of retrosternal chest pain. (Maynard et al 2000)
Hiatus hernia and acid reflux. An absence of Cardiac type symptoms (as outlined above), the presence of specific food related symptoms (eg. Onions, curries etc.), a definite correlation of symptoms and mechanical factors such as lying down, bending, straining, or carrying heavy weights, the symptoms being typically worse in the morning and easier in the afternoon. The symptoms being suddenly worse on swallowing. Any of these factors being positive would strengthen this particular diagnosis.
Cholecyctitis/ cholelithiasis. The pain being exacerbated by fatty foods and being maximal in the right hypochondrium (even if it radiates elsewhere). No clear association with dyspnoea, a temperature (as opposed to sweating), pain on deep inspiration. Any of these factors being positive would increase the likelihood of this diagnosis.
Gastric ulceration. A long time span of crescendo type symptoms. Pain typically being food related and possibly food specific ( eg. Spices and alcohol) pain coming on about 30 minutes after eating. Waterbrash symptoms, relief from antacids in the early stages. Any of these would strengthen this hypothesis.
Congestive cardiac failure. Swollen ankles, dyspnoea on effort, paroxysmal nocturnal dyspnoea (when lying flat), waking up with dyspnoea, palpitations. Progressively reduced exercise tolerance. All would increase suspicion of this diagnosis.
Hysteria/ hypochondriasis. Inconsistent, unanatomical or unphysiological symptoms, wild gesticulations, overselling of symptoms. Linking of symptoms with guilt or punishment (martyr syndrome). (Martyn. C 1999)
Tietzer's syndrome. Localised anterior chest pain, worse on deep breathing, worse on direct pressure often arises after a knock or bang.
Muscle spasm. Demonstrable trigger (sudden strain etc.), always movement specific, may be aggravated by deep breathing.
Secondary hypothesis generation and data analysis
At this stage it should be fairly easy to eliminate at least half of the provisional diagnoses. We also have to note that Mrs Singh has a significant family history with two first degree relatives having very significant cardiovascular pathology. If we also consider that she has been a heavy smoker and is a treated hypertensive and a Type II diabetic, (Adler et al 2000) we can virtually narrow the list down either myocardial ischaemia or infarction at this stage
This does not mean that we can totally exclude the other diagnoses, but they become significantly less likely.
Problem synthesis
In order to complete this section we need to consider the results of our physical examination. For the sake of argument, we will consider that we have found Mrs Singh to be uncharacteristically hypotensive (90/60), a pulse of 110 which is weak and occasionally irregular (sinus tachycardia). She is markedly dyspnoeic and listening to her chest reveals moist (fluid) sounds in both lung bases. She is obviously distressed when lying down. It is not possible to assess whether she is cyanotic.
With this clinical picture we can now reflect on the history (Gibbs, G 1998) and be reasonably confident that we can now rule out :-
- Hiatus hernia and acid reflux.
- Cholecyctitis/ cholelithiasis.
- Gastric ulceration
- Hysteria/ hypochondriasis.
- Tietzer's syndrome.
- Muscle spasm.
As consideration of the pathophysiology of each of these conditions is inconsistent with our findings.
Diagnosis and treatment decision making
At this stage we have to decide whether the Mrs Singh is suffering from myocardial ischaemia or is actually infarcting. The fact that she is hypotensive, tachycardic, dyspnoeic and in obvious heart failure, and gives a suspicious history, gives a very high index of suspicion that she is infarcting.
The treatment from the point of view of a professional nurse practitioner, is to realise that, having made the diagnosis on clinical grounds, prompt treatment is critical. In real terms, there would be no clinical justification in doing further tests at this stage, as the main clinical priority would be to get her assessed in the nearest secondary care centre, with a view to thrombolytic therapy. (Kuhse & Singer 2001)
My role would be to alert a doctor, if one was available, call a blue-light ambulance, provide oxygen, aspirin and nitrolingual spray if available(to the client, I don't know if this would be in a Nurse Practitioner's remit. PDG) and to nurse her in a sitting position.
I would also provide strong and confident professional reassurance in order to help reduce her anxiety and make arrangements to notify her family of what was happening. (Elwyn et al 2003)
Pathophysiology of myocardial ischaemia and infarction
In the normal heart, the metabolic processes are maintained in the presence of an adequate blood supply that comes from the coronary arteries. The coronary arteries are the first branch of the Aorta and therefore deliver blood at the highest blood pressure anywhere in the body. Unlike skeletal muscle, cardiac muscle is constantly in motion and constantly metabolising at an almost maximal rate. It follows that it is therefore in need of a constant supply of blood.
In the condition of myocardial ischaemia the coronary artery blood flow is reduced (usually through vessel narrowing due to atheroma) and as a result, the respiratory capacity of the myocardium is proportionately compromised. This can give rise to the variety of symptoms that we have described above.
Myocardial infarction can be thought of as an acute phase of myocardial ischaemia. This occurs when the blood flow through one particular area of the myocardium suddenly drops below a critical level - usually because of thrombus formation or an embolic process. If the situation is not resolved promptly then there is an almost inevitable degree of myocardial tissue death. This, in turn, affects the ability of the heart to function efficiently and can lead to degrees of heart failure or even death. (Donnelly et al 2000),
Conclusion
By careful consideration of all aspects of Mrs Singh's presentation, adopting a considerate and reflective approach to subsequent questioning and a careful examination, we can demonstrate how it is possible to arrive at a reasoned and rational diagnosis and treatment plan.
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Appendix A
The patient presenting problem is chest pain,this is a 56 yr old asian woman who came to see me in a gp surgery,with complaint of retrosternal chest pain,describes as a squeezing and tightness.radiation to jaw,neck and shoulder.pain began while working in her garden lasted up to 5 mins.associated symptoms are sweating and shortnss of breath.patient took antacid without relief,pain was relieved after lying down.this has been going on for the last 4 days.exacerbating factors are big meal,cold wind and exertion.patient believed the episodes are due to indigestion. Medical record showed patient has medical history of hypertension,non-insulin diabetic and ex-smoker smoked 20 cigarrettes daily,for 25 yrs,stopped 2 yrs ago.family history, father died of mi at age of 58,mother alive,history of stroke at 55.drug history atenolol and metformin,no allergies,when she came inshe was anxious regarding her condition,physical she is obese,weights 105kg,bmi is 42.6.
