Clinical Reasoning: Analyzing Mr. Anderson's Emergency Case

This case study focuses on Mr. Anderson, a 76-year-old patient admitted to the emergency department with suspected unprovoked angina. The assignment analyzes Mr. Anderson's symptoms, including fatigue, palpitations, and oedema, alongside his medical history, vital signs, ECG results (showing ST-elevation indicating Myocardial Infarction), and blood test results (revealing elevated cholesterol and LDL levels). The case study involves interpreting the information, identifying relevant and irrelevant data, recognizing inconsistencies, and prioritizing critical information. The analysis suggests that Mr. Anderson's angina is likely due to high cholesterol and atherosclerosis, potentially leading to coronary heart disease. It explores the need for further investigation, including an echocardiogram, and outlines an action plan involving monitoring, medication, and lifestyle adjustments. The study also discusses the prediction of potential outcomes, identification of problems, and establishment of goals for the patient's care, emphasizing the importance of prompt intervention to manage his cardiac condition.

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Running head: CLINICAL REASONING
Clinical Reasoning
Name of the Student
Name of the University
Author’s note

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CLINICAL REASONING
Consider pt. situation
Mr. Anderson, aged 76 years, was admitted to the emergency department of the
hospital with suspected unprovoked angina. Initial observation showed that he is suffering
from fatigue, occasional palpitations and progressive bilateral lower extremity oedema
(Source: Records in emergency department).
Collect cue/information
Review
Mr. Anderson reported that he is suffering from the extreme fatigue associated with
occasional palpitations and progressive bilateral lower extremity oedema (as per the
statement recorded by the patient).
Medical Parameters Patient’s Parameter Normal Parameter
Blood Pressure 160/90 120/80
Heart Rate 88 60 to 100 beats per minute
Respiratory Rate 22 12 to 25 per minute
Oxygen Saturation (SaO2) 95% 98 to 100 %
Body Temperature (T degree
Centigrade)
36.7 37
Table: Standard Adult General Observation (SAGO) Chart of Mr. Anderson
https://www.safetyandquality.gov.au/wp-content/uploads/2012/02/RPA-observations-policy-
directive.pdf
Figure: ECG report of Mr. Anderson taken within 5 minutes upon arrival to the Emergency
Department
PATIENT IS HAVING AN MYOCARDIAL INFARCTION, S-T ELEVATION MI
CAN YOU PLEASE TALK ABOUT THAT INSTEAD OF CHOLESTROL
Name of the test Patient Report Normal Parameter

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CLINICAL REASONING
Cholesterol (total) 7.1 mmol/L Below 5.2 mmol/L
(Boekholdt et al., 2012)
Low density lipoprotein
(LDL)
5.2 mmol/L 2.59-3.34 mmol/L (Boekholdt
et al., 2012)
High Density Lipoprotein
(HDL)
1.0 mmol/L 1.3-1.5 mmol/L
(Boekholdt et al., 2012)
Creatinine 100 0.5 to 1.1 milligrams (Boutten
et al. 2013)
Magnesium 0.66 mmol/L 2 to 4.8 mmol/L (Shay et al.,
2012)
Potassium 2.7mmol/L 3.6 to 5.2 mmol/L (Shay et al.,
2012)
Sodium 135 mmo/L 135-145 mmol/L (Shay et al.,
2012)
Troponin T <0.03mirco gram per liter <0.01 mirco gram per liter
(Shay et al., 2012)
Urea 2.6 mmol/L 2.5 to 8 mmol/L (Brisco,
Coca, Chen, Owens, McCauley,
Kimmel & Testani, 2013)
INR ratio 1.8 1.1 or below (Haibo, Jinzhong,
Yan & Xu, 2012)
Table: Blood Test Report of Mr. Anderson done after his admission in the Emergency
Department
Previous Nursing and Medical Results
On June 2016, he has been diagnosed with Gastro Oesophageal Reflux Disease (GORD). The
only medication that we used to take is Nexium (Esomeprazole) 20mg once a day for 4 weeks
(Source: Previous medical reports of the patient). However, after taking the medication for
the 4 weeks, Mr. Anderson did not return to the doctor for further consultation (as per
patient’s record). Mr. Anderson has a previous medical history of upper epigastric pain
(Source: previous medical reports and prescription).
Gather new information
 Airway: Patient can talk (airway is patent) (source: emergency dept)
 Breathing: Normal (source: emergency dept)
 Circulation: 160/90 blood pressure (source: daily check up)
 Disability: None
 Exposure: NA
Recall knowledge
DON’T WORRY ABOUT WRITING ANYTHING IN RECALL KNOWLEDGE, I WILL WRITE
ABOUT IT

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CLINICAL REASONING
Process information
Interpret
Understanding of signs and symptoms
Compare normal vs abnormal
The ECG report of the patient indicated that he is having Myocardial Infarction (MI) due to
ST elevation the presence of MI is leading to his unprovoked angina (Jneid et al., 2012).
During his admission he complained about extreme fatigue associated with occasional
palpitations and progressive bilateral lower extremity oedema. All these symptoms are
indications towards MI (Thygesen et al., 2012)
Current signs and symptoms
The blood test showed that Mr. Anderson has high level of total cholesterol, common
phenomenon at his age. However, extremely concentration of LDL (bad cholesterol) gives an
alarming sign. LDL is bad cholesterol which remains unused and the liver fail to utilize or
break this cholesterol (Tousoulis, Papageorgiou, Charakida, Siama, &Tsioufis, 2013). The
unused cholesterol gets deposited in the arteries of the heart leading to the generation of
arthrosclerosis (hardening of the arteries) and the outcome is angina (chest pain) (Nichols,
2013). It is due the presence of high cholesterol in blood; Mr. Anderson is suffering from
extreme fatigue (Six, et al., 2013). His heart is failing to pump out adequate blood in the
distant section of the body (hardening of the arteries decreases the efficiency of the heart).
This lack of blood transport is decreasing the oxygen content, leading to fatigue (Eckhardt,
DeVon, Piano, Ryan, &Zerwic, 2014).
Discriminate
Identify relevant and irrelevant information
The relevant information that has been recorded so far in case of Mr. Anderson is, he
has high level of blood cholesterol, with extremely high level of LDL that gives the
indication towards atherosclerosis, the reason behind coronary heart disease (angina)
(Tousoulis, Papageorgiou, Charakida, Siama, & Tsioufis, 2013). Irrelevant information in
case of Mr. Anderson is, he has low level of magnesium in blood and high levels of serum
creatinine.
Recognise inconsistent information
Hypomagnesium shows that Mr. Anderson still suffers from GORD. Problem in the
stomach or in the bowel interferes with the absorption of the Magnesium into the cell leading
to hypomagnesium (low level of magnesium in blood and hence, electrolyte imbalance). The
used magnesium is excreted out of kidneys. On the other hand, high level of creatinine in the
blood serum indicated defect in renal function which may be cited as another cause of
hypomagnesium(Sakaguchi, 2014).
Prioritise the most important information
Mr. Anderson has permissible level of HDL which is a positive sign as HDL takes up
the unused LDL, report them to the liver. Other important information includes:

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CLINICAL REASONING
 High level of blood cholesterol
 High level of LDL
 High blood pressure
Narrowing down information
 Patient is having
 High BP
 Normal RR
 Increased fatigue
 Occasional Palpitation
 Progressive bilateral lower extremity
Gaps in the information
There are no clear indication of the prevalence of his prior GORD disease (no
endoscopy has been conducted so far) and new occurrence of kidney problem (no proper
kidney/liver function test)
Relation
Mr. Anderson has high level of blood cholesterol (as per the blood test report) and this
high cholesterol is attributed due to high levels of LDL (Six, et al., 2013). Extra LDL is not
absorbed in the kidneys and is deposited in the arteries in the form of waxy deposits, plaques.
Plagues clog the arteries, disturbing the elasticity (Rapsomaniki, et al., 2014). This causes
hardening of the arteries; preventing normal blood flow, impart stress in heart to pump more
blood, causing chest pain or angina. Mr. Anderson is also experiencing progressive bilateral
lower extremity oedema which another principal sign of heart disease of chest pain (Six, et
al., 2013). Oedema is characterised as excessive accumulation of watery fluid in the tissues or
the cavities of the body. Oedema also occurs due to renal malfunction due to abnormal salt
retention (Shlipak, Matsushita, Ärnlöv, Inker, Katz, Polkinghorne&Levey, 2013).
Inference
The interpretation, discrimination and relation of the symptoms and the condition of
Mr. Anderson analysed so far lead to the inference that, Mr. Anderson is suffering from
angina arising out of increasing in the blood cholesterol level (Rapsomaniki, et al., 2014).
This chest pain might be the cause of coronary heart disease or ischemic heart disease. In
adverse condition, coronary heart disease may lead to heart failure or sudden cardiac arrest
(Six, et al., 2013).
His previous medical complication GORD might have got cured but the low level of
magnesium in the blood contradict that statement (Thrift, 2013).
Matching
Mr. Anderson with a past medical history of upper epigastric pain and GORD has
been admitted in the hospital with unprovoked angina. The ECG report, high blood pressure
(hypertension) and high level of total cholesterol and LDL in blood provided indication
towards the arthrosclerosis leading to chest pain of Angina (Rapsomaniki, et al., 2014). His

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CLINICAL REASONING
chest pain might also be due to the excessive smoking (Mr. Anderson smokes 15 cigarettes
per day). A high degree of chain smoking leads to the blockage of the pulmonary arteries and
vesicles which may lead to chest pain and then subsequent fatigue. Chain smoking also has a
direct connection with the cardiovascular disease (Messner& Bernhard, 2014). On the other
hand, progressive bilateral further proves the existence of certain cardiac problems. The
evidence towards the kidney problem is reflected via high level of serum creatinine (Shlipak,
Matsushita, Ärnlöv, Inker, Katz, Polkinghorne&Levey, 2013). However, Mr. Anderson has
normal level of urea, something unusual with the kidney problem (Shlipak, Matsushita,
Ärnlöv, Inker, Katz, Polkinghorne&Levey, 2013).
Prediction
The prediction of the clinical case study of Mr. Anderson is suffering from cardiac
problems and from this, he is encountering chest pain. The cardiac problem is basically due
to high levels of cholesterol in blood (Rapsomaniki, et al., 2014). This extra cholesterol is
getting deposited over the cardiac arteries, leading to its hardening and then chest pain
(Eckhardt, DeVon, Piano, Ryan, &Zerwic, 2014). Due to cardiac problem only, Mr.
Anderson is suffering from extreme fatigue and palpitations. The body is not getting adequate
oxygen in blood and hence, there occurring lack of ATP in the cells and the outcome is
fatigue. The outcome o this chest pain may be coronary heart disease or ischemic heart
disease that may lead to sudden heart attack and myocardial infarction (Eckhardt, DeVon,
Piano, Ryan, &Zerwic, 2014).
The fluid intake of Mr. Anderson must be restricted in order to deal with the oedema
because extra fluid intake might change the oedema into a fatal condition as it is in a
progressive state (Eckhardt, DeVon, Piano, Ryan, &Zerwic, 2014).
Identify Problems/issues
Mr. Anderson has high cholesterol level in blood along with high blood pressure and
thus might be suffering from Arthrosclerosis leading to coronary heart disease or ischemic
heart disease that may cause sudden heart attack and myocardial infarction (Eckhardt,
DeVon, Piano, Ryan, & Zerwic, 2014).
The most alarming and urgent issue that must be taken into consideration into an
immediate basis is high concentration of LDL (bad cholesterol). LDL remains unused and the
liver fails to utilize or break this cholesterol. This unused cholesterol gets deposited in the
arteries of the heart causing arthrosclerosis (hardening of the arteries) and the outcome is
angina (chest pain) and fatigue (Rapsomaniki, et al., 2014). The heart fails to pump out
adequate blood in the distant section of the body causing decreasing the oxygen content,
leading to fatigue (Eckhardt, DeVon, Piano, Ryan, & Zerwic, 2014).The ECG report showed
ST-elevation which indicated MI (Jneid et al., 2012).
Establishment of Goals

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CLINICAL REASONING
In order to improve the overall condition of Mr. Anderson, I want do perfrom certain basic
physiological step
1. Measure his oxygen saturation in order to know his reason of fatigue (Chen et al.,
2012) (Eckhardt, DeVon, Piano, Ryan, &Zerwic, 2014)
2. Limit his water intake in order to check the progressive bilateral lower extremity
oedema (Meeus, Goubert, De Backer, Struyf, Hermans, Coppieters&Calders, 2013)
3. Check is respiration rate as he is experiencing extreme fatigue and is refusing to step
outside the bed (Meeus, Goubert, De Backer, Struyf, Hermans, Coppieters&Calders, 2013).
Please also mention about a time frame for goals
ECG shows he is having MI therefore; the goals would be different and vary according to that
ECO cardiogram should be done to verify if it is actually an MI
Please also talk about establishing goals regarding his cholesterol levels and blood
pressureinterventions
SMART goals
• Specific: Conduct the Echo cardiogram of heart analyse the present image of heart
• Measurable: Echo cardiogram will help to identity the severity of the plaque
deposition
• Achievable: Echo cardiogram will be easy to perform
• Realistic: The goal of conducting Echo cardiogram is realistic because it will help in
the process of proper disease diagnosis (Rapsomaniki, et al., 2014)
• Timely: Echo cardiogram must be done in an urgent basis
Action Plan
Mr. Anderson is refusing to step outside the bed as he is complaining of extreme
fatigue. It is the duty of the nurse to ring the doctor to get further advise
an order to put him under through monitor machine to get a live feed of the heart rate,
respiratory rate and oxygen saturation
The attending registered nursemust also tell doctor to give orders for Echo
cardiogram, endoscopy and kidney function test. Echo cardiogram will provide images of the
heart via using standard two dimensional, three dimensional and Doppler ultrasound
techniques (Donofrio, Moon-Grady, Hornberger, Copel, Sklansky, Abuhamad&Lacey, 2014).
Endoscopy will give the actual picture of the oesophagus (Shaheen, Weinberg, Denberg,
Chou, Qaseem, &Shekelle, 2012).
Evaluation
Till now there is no improvement in patient condition has he has refused to step out of
the bed due to extreme fatigue. The nurse needs to keep a look at his blood pressure and urine
output and respiratory rate (Gottlieb, Stebbins, Voors, Hasselblad, Ezekowitz, Califf&
Hernandez, 2013).

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CLINICAL REASONING
You can also mention about keeping him on ECG monitor machine until further investigation
has not been done.
Reflection on the learning process
If I encounter with this kind of similar situation again, I will definitely not have the
same feeling of anxiety and apprehension. Moreover, Iwillconfirm that the echo cardiogram
and kidney function test done on time. I will also keep an hourly record of the oxygen
saturation, respiratory rate and urine output. Additionally, I will communicate with the
patient in order to know if he/she is experiencing any level of distress or discomfort.
Communication is the core to deliver the best quality nursing and at the same time, it helps in
minimising initial apprehension (Riley, 2015).

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CLINICAL REASONING
Extra added references:
Boekholdt, S. M., Arsenault, B. J., Mora, S., Pedersen, T. R., LaRosa, J. C., Nestel, P. J., ... &
DeMicco, D. A. (2012). Association of LDL cholesterol, non–HDL cholesterol, and
apolipoprotein B levels with risk of cardiovascular events among patients treated with
statins: a meta-analysis. Jama, 307(12), 1302-1309.
Boutten, A., Bargnoux, A. S., Carlier, M. C., Delanaye, P., Rozet, E., Delatour, V., ... &
Piéroni, L. (2013). Enzymatic but not compensated Jaffe methods reach the desirable
specifications of NKDEP at normal levels of creatinine. Results of the French
multicentric evaluation. Clinica chimica acta, 419, 132-135.
Brisco, M. A., Coca, S. G., Chen, J., Owens, A. T., McCauley, B. D., Kimmel, S. E., &
Testani, J. M. (2013). The Blood Urea Nitrogen to Creatinine Ratio Identifies a High
Risk but Potentially Reversible Form of Renal Dysfunction in Patients with
Decompensated Heart Failure. Circulation: Heart Failure, CIRCHEARTFAILURE-
112.
Haibo, Z., Jinzhong, L., Yan, L., & Xu, M. (2012). Low-intensity international normalized
ratio (INR) oral anticoagulant therapy in Chinese patients with mechanical heart valve
prostheses. Cell biochemistry and biophysics, 62(1), 147-151.
Jneid, H., Anderson, J. L., Wright, R. S., Adams, C. D., Bridges, C. R., Casey, D. E., ... &
Peterson, E. D. (2012). 2012 ACCF/AHA focused update of the guideline for the
management of patients with unstable angina/non–ST-elevation myocardial infarction
(updating the 2007 guideline and replacing the 2011 focused update). Circulation,
CIR-0b013e318256f1e0.
Shay, C. M., Van Horn, L., Stamler, J., Dyer, A. R., Brown, I. J., Chan, Q., ... & Elliott, P.
(2012). Food and nutrient intakes and their associations with lower BMI in middle-

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CLINICAL REASONING
aged US adults: the International Study of Macro-/Micronutrients and Blood Pressure
(INTERMAP). The American journal of clinical nutrition, ajcn-025056.
Thygesen, K., Alpert, J. S., Jaffe, A. S., Simoons, M. L., Chaitman, B. R., White, H. D., ... &
White, H. D. (2012). Third universal definition of myocardial infarction. European
heart journal, 33(20), 2551-2567.