1

Disease Deep Dive

Kathryn S. Crim

School of Nursing, James Madison University

NSG 461: Pathophysiology and Pharmacology

Dr. Jamie Robinson

March 26, 2021

 2

Disease Deep Dive

A 54-year-old black female presents with complaints of chest discomfort, shortness of

breath on exertion, postural lightheadedness, palpitations and mobility intolerance. On physical

exam she is in mild distress. The following diagnoses are being considered Chronic Obstructive

Pulmonary Disease (COPD), Acute Coronary Syndrome (ACS) and Pernicious Anemia (PA).

The follow paper will discuss the case study presented above and determine the mostly likely

diagnosis based on chief complaints, review of symptoms and physical exam.

Question One

COPD, ACS and Pernicious Anemia are being considered as possible diagnoses for the

patient based on the presenting signs and symptoms mentioned above. The question being

address in this portion of the paper is which diagnosis do I believe to be most likely based on the

presenting signs and symptoms. At first glance, I believe that Acute Coronary Syndrome is the

most likely consideration given her chief complaint/presenting signs and symptoms. ACS occurs

when there is a sudden coronary obstruction or blockage in the coronary arteries that occurs from

thrombus/clot formation over a ruptured plaque (McCance & Huether, 2019). This obstruction

causes ischemia; if ischemia is prolonged heart damage occurs and a myocardial infarction is

imminent. The presenting signs and symptoms are chest pain, pressure or fullness, pain that

radiates to the neck, jaw or back, nausea/vomiting, dyspnea, and light headedness (Foley, 2019).

The signs and symptoms of ACS are vague in women compared to men. Women typically delay

seeking care and treatment because symptoms such as fatigue, weakness, and dyspnea as less

obvious (Foley, 2019). The patient mentioned above fits the category of female gender with

complaints of chest discomfort, dyspnea and lightheadedness; those symptoms are vague and not

the “typical” or “obvious” symptoms which lead me to suspect ACS. The chest discomfort felt
 3

on exertion is related to ischemia that occurs in the coronary arteries, blood is unable to flow

adequately to the heart muscle which is the etiology of the pain, this can occur at rest and on

exertion. Dyspnea and light headedness are related to lack of perfusion from the ischemic

changes within the heart muscle, if the heart is unable to be perfused, cardiac output decreases

which can result in the patient feeling light headed and be short of breath.

There are some symptoms that are not consistent with ACS. Typically, it is more acute

and sudden; occurring within minutes to hours; however, with given she is a woman I took into

account my knowledge of women having less vague symptoms. The chest discomfort occurs

with exertion, in ACS the pain is present with exertion and rest. ACS could not be the diagnosis

based on the lightheadedness being postural, I correlate this to decreased cardiac output with

postural changes; however, it seems like a more chronic issue and less consistent with a one-

week history. The initial evaluation gave minimal details into the full picture; I did consider

pernicious anemia as a possibility, but ultimately decided on ACS. Further workup with

electrocardiogram and laboratory testing would need to be completed to confirm after more

throughout personal and family history.

Question Two

Upon further investigation into the patient’s history, it is determined that she has been

experiencing the above-mentioned symptoms over the past week, progressively getting worse.

She has a history of alcohol use, is a current smoker (1 pack per day) and has hypertension which

she takes candesartan. Her current vital signs indicate that she is hypertensive; mild, with her

systolic BP 136. All other vital signs are not significantly concerning. The question addressed

in this portion is related to which diagnosis would you exclude after reviewing her history. The

diagnosis that can be excluded would be COPD. The reason for excluding COPD is based on the
 4

information that her symptoms have been present for one week. COPD is an umbrella term that

covers chronic bronchitis and emphysema (McCance & Huether, 2019). COPD is a chronic

illness with symptoms lasting at least 3 months for at least 2 consecutive years, symptoms such

as cough, increased sputum production, shortness of breath, hypoxemia with Sp02 levels less

than 88% (McCance & Huether, 2019). The patient in question is experiencing shortness of

breath, but is able to maintain her oxygenation saturations at 93% on room air. Another

indication that COPD can be excluded is the lack of cough or increased sputum production. She

does have a history of smoking which is a risk factor for obstructive lung disorders; however, no

other clinical data match this diagnosis. No documentation of recurrent respiratory illness such

as colds, there is mention of Epstein Barr virus (EBV) in her history; but I do not believe there is

a link with EBV and COPD. The patient is experiencing symptoms that are progressively getting

worse over the past week, they include symptoms similar to COPD such as dyspnea and

functional limitations in mobility, but most importantly the timeline is not consistent with a

chronic illness. Based on my opinion, this is an acute process which makes me exclude COPD

from being a possible diagnosis for this patient.

Question Three

The review of symptoms reveals new information: a weight gain of six pounds over the

past two months, poor appetite, joint pain that improves with movement, JVD, trace peripheral

edema in her lower extremities, some nocturia, and anxious feeling. Laboratory findings suggest

an elevated Troponin level at 0.50, increased LDH, increased triglycerides, and increased blood

glucose. Based on these new findings and her clinical presentation, I do support the diagnosis of

ACS. Coronary artery disease (CAD) occurs when atherosclerosis clogs the coronary arteries

and impede the blood flow to the heart, this process continues until complete occlusion resulting
 5

in ischemia and myocardial infarction (McCance & Huether, 20190. When CAD progresses,

ACS can occur when complete occlusion occurs. A person diagnosed with ACS, typically will

have CAD whether it is diagnosed or not. CAD impairs the hearts ability to pump blood to the

body; therefore, altering perfusion and the functionality of other body systems.

The risk factors associated with ACS are hypertension, obesity, diabetes, hyperlipidemia,

cigarette smoking, African American, and sedentary lifestyle (McCance & Huether, 2019). The

patient has elevated cholesterol levels indicating possible atherosclerotic changes in her arteries.

Another risk factor is her history of smoking, she currently smokes one pack per day for the past

10 years. Smoking causes the release of catecholamines which increase the heart rate and cause

peripheral vasoconstriction which results in BP increasing as well as cardiac work load and

oxygen demand (McCance & Huether, 2019). Hypertension is a risk factor as well, our patient

mentioned earlier has a history of hypertension which she takes candesartan. Hypertension has

been studied to be an independent risk factor for multivessel disease (MVD) leading to increased

cases requiring immediate intervention (Ge et al., 2018). No weight was listed to question if

obesity is a factor. Diabetes is a risk factor as high glucose levels damage the endothelium of the

blood vessels with can lead to increased thrombosis, her BG level were elevated at 226;

however, her A1c was good at 6.9%. This is noteworthy and worth monitoring closely. An

important laboratory finding was the troponin level; 0.50. Troponin is a serum protein that is

used as a cardiac marker to determine if ischemia is occurring, it is often measured every hour

for three hours (Alghamdi et al., 2020).

To conclude, it is determined in my opinion that ACS is the best diagnosis based on the

clinical presentation, examination and laboratory findings. The patient presents with symptoms

of chest discomfort on exertion with dyspnea x one week, presuming it to be an acute process.
 6

The chest discomfort she is experiencing is associated with myocardial ischemia related to

atherosclerosis in her coronary arteries. The heart is a muscle and when perfusion is not

adequate, cramp/pain occurs as a result. This correlates with her elevated cholesterol levels and

cardiac enzyme marker, troponin. Currently, her chest pain is occurring with exertion; however,

this can progress quickly and become painful even at rest, known as unstable angina. In regards

to her complaints of lightheadedness and shortness of breath, this is consistent with decreased

cardiac output and altered perfusion to organs as a result of decreased blood flow to the heart.

The heart then has to work harder and over time causes the walls of the left ventricle to become

larger; ultimately, affecting cardiac output even more. It is possible our patient is experiencing

some signs of cardiomyopathy based on her exam findings: JVD, weight gain, and peripheral

edema.
 7

References

Alghamdi, A., Reynard, C., Morris, N., Moss, P., Jarman, H., Hardy, E., Harris, T., Horner, D.,

Parris, R., & Body, R. (2020). Diagnostic accuracy of the Troponin-only Manchester

Acute Coronary Syndromes (T-MACS) decision aid with a point-of-care cardiac troponin

assay. Emergency Medicine Journal, 37(4), 223–228. https://doi.org/10.1136/emermed-

2019-208882

Foley A. L. (2019). Not Just Chest Pain: Presenting Symptoms of Acute Coronary Syndrome by

Gender: A Research to Practice Summary. Journal of emergency nursing, 45(4), 462–

464. https://doi.org/10.1016/j.jen.2019.05.004

Ge, J., Li, J., Yu, H., & Hou, B. (2018). Hypertension Is an Independent Predictor of Multivessel

Coronary Artery Disease in Young Adults with Acute Coronary Syndrome. International

Journal of Hypertension, 1–9. https://doi.org/10.1155/2018/7623639

McCance, K., & Huether, S. (2019). Pathophysiology The biologic basis for disease in adults and

children, 8th ed. Mosby.