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Assessing Risk, Negotiating for BehaviorChange, Respecting Culture
Problem-Based LearningForNursing StudentsUpdated 2008
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Author:MaryR.Dortenzo,M.S.N.,N.P.-C
ProgramCoordinator:WomensSpecialtyProgramsMagee-WomensHospitaloftheUniversityofPittsburghMedicalCenterPittsburgh,PAUpdated(2008):JanetPregler,MDProfessorofClinicalMedicineDirector,IrisCantor-UCLAWomensHealthCenterDavidGeffenSchoolofMedicineatUCLAThe Heart Truth Professional Education Campaign Development Working Group
RaminAhmadi,M.D.,M.P.H.President,GriffinFacultyPracticeDirector,InternalMedicineResidencyProgram,GriffinHospitalDerby,CTR.AnnAbercrombie,M.L.S.OutreachLibrarianUnitedStatesDepartmentofHealthandHumanServices,OfficeonWomen'sHealthWashington,D.C.
DeliaAnderson,M.A.ExecutiveDirector,ProgramfortheTeachingandAssessmentofProfessionalSkillsTulaneUniversitySchoolofMedicineNewOrleans,LAElizabethA.Bisinov,M.D.AssistantProfessorofMedicine,CardiologySectionUniversityofWisconsinMadison,WI
CherylL.Bord,A.P.R.N.,B.C.NursePractitioner/CoordinatorWomensHeartProgramUniversityofMichiganHealthSystemPlymouth,MI
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SusanM.Clark,M.A.Director,DivisionofProgramManagementUnitedStatesDepartmentofHealthandHumanServices,OfficeonWomen'sHealthRockville,MD
WalterJ.Clark,M.D.MedicalDirectorNortheastOhioNeighborhoodHealthServices,Inc.CommunityCenterofExcellenceinWomensHealthAssistantClinicalProfessorofMedicineCaseWesternReserveSchoolofMedicineCleveland,OHKateCronin,M.P.H.ResearchProgramManagerNationalCentersofExcellenceResearchCoordinatingCenterUniversityofWisconsinCenterforWomensHealthResearchMelissaCuppy,R.N.NortheastMissouriHealthCouncilCommunityCenterofExcellenceinWomensHealthKirksville,MOMicheleDavid,M.D.,M.B.A.,M.P.H.Director,HaitianHealthInstituteatBostonMedicalCenterWomensHealthResearchUnitNationalCenterofExcellenceinWomensHealthBostonUniversityMedicalCenterBoston,MA
MaryR.Dortenzo,M.S.N.,N.P.-CProgramCoordinator:WomensSpecialtyProgramsMagee-WomensHospitaloftheUniversityofPittsburghMedicalCenterPittsburgh,PAPamelaS.Douglas,M.D.,F.A.C.C.,F.A.S.E.UrsulaGellerProfessorofResearchinCardiovascularDiseasesChief,DivisionofCardiovascularMedicineDukeUniversityMedicalCenterDurham,NC
KaiytiDuffy,M.P.H.SeniorProgramCoordinatorSt.BarnabasCommunityCenterofExcellenceinWomensHealthNewYork,NY
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ClaireS.Duvernoy,M.D.Director,WomensHeartProgramUniversityofMichiganHealthSystemVeteransAffairsMedicalCenterCardiologySectionAnnArbor,MI
KarenFreund,M.D.,M.P.H.ProfessorofMedicineDirector,BostonUniversityCenterofExcellenceinWomensHealthBostonUniversitySchoolofMedicineBoston,MAGeraldeV.Gabeau,M.M.ProgramCoordinator,BostonUniversityCenterofExcellenceinWomensHealthBostonUniversityMedicalCenterBoston,MAMelissaGilliam,M.D.,M.P.H.AssistantProfessorofObstetricsandGynecologyUniversityofIllinois,ChicagoChicago,ILGinaGilliland,R.N.C.,W.H.N.P.ProjectCoordinator,NortheastMissouriHealthCouncilCommunityCenterofExcellenceinWomensHealthKirksville,MO
DarleneHardimonQualityImprovementCoordinatorNortheastOhioNeighborhoodHealthServices,Inc.Cleveland,OHSuzanneG.Haynes,Ph.D.SeniorScienceAdvisorUnitedStatesDepartmentofHealthandHumanServices,OfficeonWomensHealthWashington,D.C.MandyHerleth
NortheastMissouriHealthCouncilCommunityCenterofExcellenceinWomensHealthKirksville,MOSharonHillier,Ph.D.Director,Magee-WomensHospitalNationalCenterofExcellenceinWomensHealthProfessorofObstetricsandGynecologyUniversityofPittsburghPittsburgh,PA
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DixieHorningExecutiveDirector,UCSFWomensHealthCenterSanFrancisco,CA
BarbaraF.James,M.P.H.
SeniorHealthScienceAnalystDirector,NationalCommunityCentersofExcellenceinWomensHealthProgramUnitedStatesDepartmentofHealthandHumanServices,OfficeonWomensHealthRockville,MDMaryKennedy,D.O.MedicalAdvisor,WomensHealthGrantsNortheastMissouriHealthCouncilCommunityCenterofExcellenceinWomensHealthKirksville,MOAnnaL.Kindermann,J.D.PublicHealthAnalystUnitedStatesDepartmentofHealthandHumanServices,OfficeonWomensHealthRockville,MDLacieKoppelman,M.S.P.H.PublicHealthAdvisorUnitedStatesDepartmentofHealthandHumanServices,OfficeonWomensHealthRockville,MDCathyJ.Lazarus,M.D.,F.A.C.P.ProfessorofMedicine
TulaneUniversitySchoolofMedicineNewOrleans,LAJaneA.Leopold,M.D.AssistantProfessorofMedicineHarvardMedicalSchoolBrighamandWomensHospitalDivisionofCardiovascularMedicineBoston,MASusanM.Nappi,ProgramDirector
NationalCommunityCenterofExcellenceinWomensHealthatGriffinHospitalDerby,CTTerryLongCommunicationsDirectorNationalHeart,Lung,andBloodInstituteNationalInstitutesofHealthBethesda,MD
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JeanetteH.MagnusM.D.,Ph.D.Director,TulaneXavierNationalCenterofExcellenceinWomensHealthProfessorofMedicineTulaneUniversitySchoolofMedicineNewOrleans,LA
MelissaMcNeil,M.D.DirectorofProfessionalEducation,Magee-WomensHospitalNationalCenterofExcellenceinWomensHealthProfessorofMedicinePittsburgh,PANancyMilliken,M.D.Director,UCSFNationalCenterofExcellenceinWomensHealthDirector,UCSFWomensHealthCenterAssociateClinicalProfessorofObstetrics,Gynecology&ReproductiveSciencesUniversityofCalifornia,SanFranciscoSanFrancisco,CACindyS.Moskovic,M.S.W.Director,IrisCantorUCLAWomensHealthEducation&ResourceCenterDavidGeffenSchoolofMedicineatUCLALosAngeles,CAEileenP.Newman,M.S.,R.D.PublicHealthAnalystUnitedStatesDepartmentofHealthandHumanServices,OfficeonWomensHealthRockville,MD
AnaE.Nez,M.D.Director,DrexelUniversityNationalCenterofExcellenceinWomensHealthAssociateProfessorofMedicineDrexelUniversityCollegeofMedicinePhiladelphia,PAMicheleOndeck,R.N.,M.Ed.ClinicalResearchCoordinator,Magee-WomensHospitalAssistantDirector,Magee-WomensHospitalNationalCenterofExcellenceinWomensHealth
Pittsburgh,PADhavalPatelMedicalStudentTulaneUniversitySchoolofMedicineNewOrleans,LA
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ChristinaAlbertinPetranek,M.P.H.EvaluationCoordinatorNationalCommunityCenterofExcellenceinWomensHealthatGriffinHospitalDerby,CT
JanetP.Pregler,M.D.Director,UCLANationalCenterofExcellenceinWomensHealthDirector,IrisCantor-UCLAWomensHealthCenterProfessorofClinicalMedicineDavidGeffenSchoolofMedicineatUCLALosAngeles,CATaraRizzo,M.P.H.EpidemiologistandProgramCoordinatorNationalCommunityCenterofExcellenceinWomensHealthatGriffinHospitalDerby,CTCandaceRobertson,M.P.H.DeputyDirector,DrexelUniversityNationalCenterofExcellenceinWomensHealthDrexelUniversityCollegeofMedicinePhiladelphia,PAKimberlyD.SandersProgramDirectorNortheastOhioNeighborhoodHealthService,Inc.NationalCommunityCenterofExcellenceinWomensHealthCleveland,OH
GloriaSarto,M.D.,Ph.D.Co-Director,UniversityofWisconsinCenterforWomensHealthResearchProfessorofObstetricsandGynecologyUniversityofWisconsinSchoolofMedicineMadison,WIValerieScardino,M.P.A.NWHICProgramManagerUnitedStatesDepartmentofHealthandHumanServices,OfficeonWomensHealthWashington,DC
MargaretR.Seaver,M.D.,M.P.H.DeputyDirector,BUNationalCenterofExcellenceinWomensHealthDirector,WomenVeteransHealthCenterAssistantProfessorofMedicineBostonUniversitySchoolofMedicineBoston,MA
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KitShelbyStandardizedPatientTrainerProgramfortheTeachingandAssessmentofProfessionalSkillsTulaneUniversitySchoolofMedicineNewOrleans,LA
BonnieJ.Sherman,Ph.D.ResearchAssociateBostonUniversityNationalCenterofExcellenceinWomen'sHealthBostonUniversitySchoolofMedicineBoston,MAMarjorieKagawa-Singer,Ph.D.,M.N.,R.N.Director,ConcurrentPrograminCommunityHealthSciencesandAsianAmericanStudiesAssociateProfessorUCLASchoolofPublicHealthLosAngeles,CAAnnM.Taubenheim,Ph.D.,M.S.N.Coordinator,Women'sHeartHealthEducationInitiativeOfficeofPrevention,Education,andControlNationalHeart,Lung,andBloodInstituteBethesda,MDJustinaA.Trott,M.D.,F.A.C.P.Director,SantaFeNationalCommunityCenterofExcellenceinWomensHealthDirector,WomensHealthServicesFamilyCareandCounselingCenter
ClinicalProfessorofMedicineUniversityofNewMexicoSchoolofMedicineSantaFe,NMMiltaVega-Cardona,M.S.A.,C.S.A.C.ProjectManagerSt.BarnabasNationalCommunityCenterofExcellenceinWomensHealthNewYork,NYKarolE.Watson,M.D.,Ph.D.Co-director,UCLAPrograminPreventiveCardiology
AssistantProfessorofMedicineDavidGeffenSchoolofMedicineatUCLALosAngeles,CA
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The Heart Truth Professional Education ProgramProblem-based Learning for Nursing Students
TableofContentsIntroduction....................................................................................... I-1toI-3 TheCaseofMrs.MontoyaFacilitatorsGuide...............................FG-1toFG-24TheCaseofMrs.MontoyaStudentMaterials............................... S-1toS-14ExaminationQuestions.................................................................... E-1toE-8ExaminationQuestionsAnswerKey................................................AK-1toAK-8ReferencesandResources......................................................... R-1toR-5
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IntroductionThe Heart Truth Professional Education ProgramProblem-based Learning for Nursing Students
EducationalGoalsFornursingstudents:
Torecognizegenderdifferencesintheepidemiology,diagnosis,andtreatmentofheartdisease
TorecognizethatheartdiseaseistheleadingcauseofdeathinAmericanwomenofallethnicities
TargetedLearnersTheseproblem-basedlearningcasesareforbothbeginnerandadvancedstudents.Sectionswithinthecasemodulecanbeselectedbasedonthelearnersstageofknowledgeandthelearnersplacementwithintheinstitutionsestablishedcurriculum.Mostinstructorswillfindthesematerialsworkbestifbeginnerstudents(asanexample,second,third,andfourthyearnursingstudents)areencouragedtotackleissuesrelatedtobasicknowledgeofcardiovasculardisease(CVD)suchas:
prevalenceandincidencedata,includingracial,ethnicandgenderdifferences riskfactoridentification,includingracial,ethnicandgenderdifferences
intheprevalenceandincidenceofriskfactors preventionstrategies,focusingonlifestylebehavioralchangeswithinthecontext
ofculturaldiversity,ethnicity,raceandgenderdifferencesFortheadvancedlearners(fourthyearnursingstudentsandnursepractitionerstudents),thesecaseslendthemselvestolearningissuesrelatedtoclinicalinterventionsforCVD,including:
conceptsofriskstratificationandriskreductionstrategies nationalguidelinesfortheprevention,treatmentanddiagnosisofCVD availableresourcesforimplementingguidelines,suchas
o resourcesforpatientso toolstoassistclinicaldecisionmaking
strategiestofacilitatebehaviorchangesinwomeno behavioralchangetheoryo professionalcommunicationo culturalcompetency
I-1
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PlaceintheCurriculumThiscaseanditsaccessorycomponentsaremeanttosupplementtheusers
establishedcurriculumforcardiovasculardisease.Thesecasesaredesignedtoimprovestudentsknowledgeandskillsaboutapproachingprevention,diagnosis,andtreatmentofcardiovasculardiseaseinwomen.Priortocasepresentationtothestudents,itisrecommendedthatthestudentshavereceivedabasicintroductiontotheanatomy,histologyandphysiologyoftheheart,aswellastothehistoryandphysicalexamination.AdditionalMaterialsAdditionalmaterialscreatedforTheHeartTruthProfessionalEducationProgramincludeacasedevelopedandtestedformedicalstudentsandastandardizedpatientcase.Coursechairsandothersinvolvedincurriculardevelopmentareencouragedtoreviewtheseadditionalmaterialsandtouseand/oradaptthemforthenursingcurriculumasappropriate.EssentialKnowledge,Skills,andBehaviorstoBeDemonstrated:Thebeginninglearnerwillbeableto:
CiteprevalenceandincidencedataofCVDandidentifyracialandgenderdifferencesinCVDprevalenceandincidence
IdentifyknownCVDriskfactorsinwomen Identifygenderandracialdifferencesintherelativeimportanceofthevariousrisk
factorsforwomen DefinetheconceptofCVDriskstratification Identifyriskreductionstrategies,includingthoseinvolvinglifestylebehavioral
changes Summarizethecurrentstateofknowledgeofhowmenopauseandhormone
therapyaffectawomansriskfordevelopingCVD CalculateBMI Identifycommon(typical)presentationsofCVDandidentifygenderdifferencesin
presentationTheadvancedlearnerwillbeableto:
Identifyevidence-basedpatienteducationresourcestosupportprimaryandsecondarypreventionandtreatmentofheartdisease
Calculateawomans10-yearriskforCVDeventsusingtheFraminghamcriteria CitetheFiveAsforbehavioralcounselinginsmokingcessation Describethepathophysiologyofstableandunstablecoronarysyndromes
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Recognizetherangeofcommonclinicalpresentationsforstableandunstablecoronarysyndromesinwomenandcontrastthesewiththoseofmen
Describetestingmodalitiesfordiagnosingcoronaryheartdiseaseandexplaindifferencesintestsensitivityandspecificityforcommontestsbygender
Listappropriateinitialdiagnostictests(thoseusuallyperformedintheemergency
department)forafemalepatientpresentingwithpossibleacutecoronarysyndrome
AdditionalKnowledge,SkillsandAttitudesforStudentsUsingtheComplementaryStandardizedPatient(SP)Case/Video:
Thestudentwillbeableto:
StatewhatbiasesmayleadtothefailuretodiagnoseCVDinwomen Identifypsychosocialfactorsthatinfluence,interferewithordelaywomen
seekingtreatmentandearlyevaluationforsymptomssuggestiveofCVD Recognizethatgender-specificandculture-specificcommunicationstylesmay
impacttheclinician-patientinteraction Applybehavioralchangetheoriesandstrategiestoclinicalsituations Identifystageofchangereadinessforthestandardizedpatientandunderstand
howthisimpactsherabilitytomodifylifestylehabitsandbehaviors Identifythepatientsbarrierstochange Developaplantomanagebarriersandtomovethepatienttowardahigherstage
ofreadiness
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The Case of Mrs. Montoya:Nursing Problem-based Learning CaseFacilitators Guide
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The Case of Mrs. Montoya: Facilitators Guide
Case Overview: The Case of Mrs. Montoya
Problem-basedLearning(PBL)TUTORGUIDENOT For Distribution To Students
EducationalGoalsFornursingstudents:
Torecognizegenderdifferencesintheepidemiology,diagnosisandtreatmentofheartdisease
TorecognizethatheartdiseaseistheleadingcauseofdeathinAmericanwomenofallethnicities
TargetedLearnersTheseproblem-basedlearningcasesareforbothbeginnerandadvancedstudents.Sectionswithinthecasemodulecanbeselectedbasedonthelearnersstageofknowledgeandthelearnersplacementwithintheinstitutionsestablishedcurriculum.Mostinstructorswillfindthesematerialsworkbestifbeginnerstudents(asanexample,second,third,andfourthyearnursingstudents)areencouragedtotackleissuesrelatedtobasicknowledgeofcardiovasculardisease(CVD)suchas:
prevalenceandincidencedata,includingracial,ethnicandgenderdifferences riskfactoridentification,includingracial,ethnicandgenderdifferences
intheprevalenceandincidenceofriskfactors preventionstrategies,focusingonlifestylebehavioralchangeswithinthecontext
ofculturaldiversity,ethnicity,raceandgenderdifferencesForadvancedlearners(fourthyearnursingstudentsandnursepractitionerstudents),thesecaseslendthemselvestolearningissuesrelatedtoclinicalinterventionsforCVD,including:
conceptsofriskstratificationandriskreductionstrategies nationalguidelinesfortheprevention,treatmentanddiagnosisofCVD availableresourcesforimplementingguidelines,suchas
o resourcesforpatientso toolstoassistclinicaldecisionmaking
strategiestofacilitatebehaviorchangesinwomeno behavioralchangetheoryo professionalcommunicationo culturalcompetency
PlaceintheCurriculumThiscaseanditsaccessorycomponentsaremeanttosupplementtheusersestablishedcurriculumforcardiovasculardisease.Thesecasesaredesignedtoimprovestudentsknowledgeandskillsaboutapproachingprevention,diagnosisand
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The Case of Mrs. Montoya: Facilitators Guide
treatmentofcardiovasculardiseaseinwomen.Priortocasepresentationtothestudents,itisrecommendedthatthestudentshavereceivedabasicintroductiontotheanatomy,histology,andphysiologyoftheheart,aswellastothehistoryandphysicalexamination.
EndingstotheCaseThiscasecanbeusedinyourPBLsmallgroupusingthreedifferentapproaches.Therearetwodifferentendingstothecase.Eitherofthesetwoendingscanbeusedseparately.However,thecaseismeanttoincorporateeither/orEndingOneorEndingTwodependingonthechoicesmadebythestudentsinthegroup.EndingOneEndingOneconcludeswhenthepatient,Mrs.Montoya,a58year-oldLatinawomanpresentsattheemergencydepartment(ED)afteramassivemyocardialinfarction(MI).Thestudentsdonotappropriatelyidentifyorwork-upthecardiacdiseasesymptomsintheoutpatientsetting.Therefore,Mrs.MontoyapresentstotheEDwithanMIweeksafterhervisit.EndingTwoEndingTwoiscompletelydifferentbasedonthestudentschoicesinregardstothedifferentialdiagnosisandplanofcare.Mrs.Montoyaundergoesadobutaminestresstolerancetestthatrevealshercardiacdiseaseandshesubsequentlyundergoesafour-vesselcoronaryarterybypassgraftsurgery.CaseFlowAttheendofSessionOne,thestudentsshouldhaveCVDontheirnursingassessment
forMrs.Montoya.Otherproblemsonthelistmightincludedepression,asthma,anemia,breastcancer,hypothyroidism,anddiabetes.WhentheyreturnforSessionTwo,thestudentswillneedtodecideaplanofnursingcare/managementapproachforMrs.Montoya.Discussionaboutwhatlabtestsmightbebeneficialand/orwhattesting/proceduresmightbeindicatedtofurtherwork-upMrs.Montoyascomplaintsisnecessary.Testresultswillnotbeimmediatelyavailabletothestudents.Instead,thetutorwillgivethestudentsthetestresult/sonlyforthetestthestudentsrequestwitharationalegivenforeachtestordered.
IfthestudentsrequestanECGtheywillreceiveacopyofanormalECG.Iftheyrequestastresstest(anytype),theywillreceivetheresultsofadobutaminestresstolerancetest.
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The Case of Mrs. Montoya: Facilitators Guide
IfthestudentsrequestastresstestandcanjustifythetestbecauseofMrs.Montoyascardiacriskfactors(familyhistory,highBMI,elevatedcholesteroldespitemedication,andhypertension),dyspneaonexertionandchestdiscomfortwithexertion,thenthetutorshouldproceedwithEndingTwo.
IfthestudentsdonotrequestastresstestthenthetutorshouldproceedwithEndingOne.Thisallowsthestudentstoseetheconsequencesofmissingthediagnosis.AfterreviewingEndingOne,thefacilitatorshouldencouragestudentstodiscusswhatmighthaveoccurredifhercardiacriskfactorshadbeenassessedproperly.TipItmaybehelpfultoprovideEndingOneandEndingTwotothetutorusingtwodifferentcoloredpaperstomakeiteasiertodistributethecorrectendingdependingonthegroupsactions.EssentialKnowledge,Skills,andBehaviorstoBeDemonstrated:Thebeginninglearnerwillbeableto:
CiteprevalenceandincidencedataofCVD,andidentifyracialandgenderdifferencesinCVDprevalenceandincidence
IdentifyknownCVDriskfactorsinwomen Identifygenderandracialdifferencesintherelativeimportanceofthevariousrisk
factorsforwomen DefinetheconceptofCVDriskstratification Identifyriskreductionstrategies,includingthoseinvolvinglifestylebehavioral
changes Summarizethecurrentstateofknowledgeofhowmenopauseandhormone
therapyaffectawomansriskfordevelopingCVD CalculateBMI Identifycommon(typical)presentationsofCVDandidentifygenderdifferencesin
presentationTheadvancedlearnerwillbeableto:
Identifyevidence-basedpatienteducationresourcestosupportprimaryandsecondarypreventionandtreatmentofheartdisease
Calculateawomans10-yearriskforCVDeventsusingtheFraminghamcriteria CitetheFiveAsforbehavioralcounselinginsmokingcessation Describethepathophysiologyofstableandunstablecoronarysyndromes Recognizetherangeofcommonclinicalpresentationsforstableandunstable
coronarysyndromesinwomenandcontrastthesewiththoseofmen
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The Case of Mrs. Montoya: Facilitators Guide
Describetestingmodalitiesfordiagnosingcoronaryheartdiseaseandexplaindifferencesintestsensitivityandspecificityforcommontestsbygender
Listappropriateinitialdiagnostictests(thoseusuallyperformedintheemergencydepartment)forafemalepatientpresentingwithpossibleacutecoronarysyndrome
AdditionalKnowledge,SkillsandAttitudesforStudentsUsingtheComplementaryStandardizedPatient(SP)Case/Video:
Thestudentwillbeableto:
StatewhatbiasesmayleadtothefailuretodiagnoseCVDinwomen Identifypsychosocialfactorsthatinfluence,interferewithordelaywomen
seekingtreatmentandearlyevaluationforsymptomssuggestiveofCVD Recognizethatgender-specificandculture-specificcommunicationstylesmay
impacttheclinician-patientinteraction
Applybehavioralchangetheoriesandstrategiestoclinicalsituations Identifystageofchangereadinessforthestandardizedpatientandunderstand
howthisimpactsherabilitytomodifylifestylehabitsandbehaviors Identifythepatientsbarrierstochange Developaplantomanagebarriersandtomovethepatienttowardahigherstage
ofreadiness
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The Case of Mrs. Montoya: Facilitators Guide
SessionOne/PartOneTodayaspartofyourclinicalrotation,youareintheoutpatientclinic.YournursinginstructorasksyoutobeinvolvedinthecareofMs.AmparoMontoya,a58year-oldLatinawomanwhoisareturningpatienttoclinic.Youentertheroomandaskwhat
bringshertoclinictoday.Shetellsyouthatherclosefriendhasbeendiagnosedwithbreastcancerandnowsheisworriedtoo.Icantfeelalumprightnow,butneitherdidshe.Shethinksherlastmammogramwastwoorthreeyearsago.Yousee,Itakecareofmylittlegrandson,Robert,becausemydaughterandherhusbandbothworkandifIhavetocometothedoctor,mydaughterhastostayhometotakecareofhim.Iwanttohelpher,notbeaburdentoher.TodayshetookoffacoupleofhourssoIcouldcomein.Imsoworried,myfriendjusthadsurgeryandshesstartedchemo.Imsoworriedaboutthecaresheisgoingtoreceive.ShedoesntspeakEnglish.Thechemonursescantfindaninterpreter.Shessotired.Igettiredsometimestoo.IthinkitsjustbecauseRobertissuchabusyboy!Hestwoandhehaslotsofenergy!Butwhatifitscancer?Itakecareofmyfamily,Icantaffordtobesick,toomanypeoplecountonme.Youacknowledgeherfamilialresponsibilities;herconcernforherfriendaswellastheconcernforherownhealthandaskherCanyoutellmeaboutyourlastmammogramvisit?Howwasthatexperience?Imcuriousastowhyyouvenotbeenback.NotgoodMrs.Montoyareplies.Ididntwanttogobacktherebecauseofconfusionwithmyinsurance,ittooksolongandIhadtogetbacktoRobertandIheardonthe
newsthatannualmammogramsmightnotbeneeded.KeyExercisePriortoContinuingOntoPartTwoHavethestudentsformulatealistofpatientinterviewquestionspriortothenextsession.Askthemtoconsiderandincluderationaleforthequestionsselected.Facilitatesmallgroupdiscussionaboutproposedinterviewquestionsduringthenextsessionandpriortomovingontothenextphaseoflearning.LearnerPrompts/SuggestedTopicsforDiscussion
Communication:provider/patientinteraction,languageofpreference,useofinterpretersandinfluenceoninteractions
Conveyingempathyandrespecttosetthestageforcommunications/interactions,buildtrustingrelationship,tangibleproviderquestionstoask,statementstomake
Ethnic/culturaldiversityinquiringaboutethnicheritage Latinoculture,identifyingculturalissuesandconflicts;theconceptofwomen
holdingon(aguantar)-seeking/accessinghealthcarelaterthansooner(attitudinalbarriersandprocessbarriers)
Healthissuesrelatedtomenopause
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The Case of Mrs. Montoya: Facilitators Guide
Chief/primarycomplaint FatigueSpanishconnotationversusEnglishconnotation;understandingwhat
thepatientmeansbyusingthewordfatigue;causesoffatigue Additionalbarrierstoseekinghealthcare
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The Case of Mrs. Montoya: Facilitators Guide
SessionOne/PartTwoYouassureMrs.Montoyathatyouwilldiscussherbreasthealthconcernswiththephysician,butthatyouwouldliketoaskafewquestionsfirst.Youtellherthatyou
understandthewordfatiguecanmeanmanydifferentthingstomanydifferentpeopleindifferentculturesandaskher,Whatdoesbeingfatiguedmeantoyou?Shetellsyouthatshehasfeltabitmoretiredforthepastfewweeks.Youaskhertoexplainhertirednessmore.BesideschasingafterRobertallday,maybeitsbecauseIdontsleepverywell.Iwakeupatfourorfiveinthemorningandcantgetbacktosleep.Shenoticesmildshortnessofbreathwhenplayingwithhimatthepark,whichsheattributestoherasthma.Shehasahistoryofmildasthmasincechildhoodandoccasionallyusesanalbuterolinhaler.Shehasnevertakensteroidsforherasthma.Shereportsthatsheneverhasshortnessofbreathwhileatrestandhasneverexperiencedanychestpain.Shereportsthatalthoughsheneverseemstogetenoughsleep,shestillhasenergytocookforherfamily,dotheshopping,andkeepupthehouse.YoufindthatMs.Montoyadoesnothavebreastpain;shehasnotnoticedanydischargefromhernipples,anydimpling,oranyotherchangestoherbreasts.Shedoesntusuallydoamonthlybreastexamsoshesnotsureifsheshadanybreastlumpsinthepastornot.Idontthinkanyoneinmyfamilyhashadbreastcancer,notthatIknowof.Myunclehadlungcancer,buthesmokedalotafterhemovedtothiscountry.Otherwise,myfamilyisprettyhealthynowexceptbothmyparentshavehighbloodpressure.Myfather
hadaheartattackabout15yearsagowhenhewas61.ThatswhentheymovedinwithmysisterinElSalvador.Iworryaboutthemallthetime,butImsuremysisteristakinggoodcareofthem.Hehadtohavesurgeryforhisheartbackthen,buthesdoingoknow.Mymomandbrotherhavediabetes,buttheyremostlyoktoo,theytrytoeatbetter,butitshard.Itrytocookthethingsthedoctorsaidtomake,but.Sheshrugs.Mytwoyoungersistersandmychildrenareveryhealthynodiabetes,nohighbloodpressure,nocancer.Myhusbandtakesmedicationeverydayforhighbloodpressuretooandhetakesanaspirinforhisheart.Iworryhellhaveaheartattacklikemyfather;heworkstoohard.Shehashadnochangesinherweight.Shereportsthatherappetiteisfair,butthatshe
sometimesjustdoesntfeellikeeating.Youaskabouthermoodandshestatessheworriesalotaboutherfamily.Herdaughterandson-in-lawlivenearbyandshetakescareofhergrandsonfull-time.Youaskherifshehaseverhadanypressureordiscomfortinherchest.Shereplies,SometimeswhenImplayingintheparkwithmygrandson.
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The Case of Mrs. Montoya: Facilitators Guide
Shesaysthatshedoesnothaveacough,althoughherson-in-lawsmokes.Neithershenorherhusbandsmokeandsheonlyallowsherson-in-lawtosmokeoutdoors.KeyExercisePriortoContinuingOntoPartThree
Atthispoint,askthestudentstothinkaboutandconsiderwhattheynowknowaboutMrs.Montoya.Havethemstartalistincludingpastmedicalhistoryandreviewofsystemsinformation.AskthestudentsWhatareyouconcernedaboutwithMrs.Montoyaandherpresentationtotheclinic?LearnerPrompts/SuggestedTopics
Stressinwomenslives Symptomsofstress Cultural/racialdifferencesregardingtriggersofstress Roleracismplaysinlifelongattitudestowardshealthcareindividualand
institutional
Breasthealthguidelinesandrecommendations Riskfactorsforpoorhealthoutcomes Symptomsofmenopause Pastmedicalhistory Additionalsymptoms
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The Case of Mrs. Montoya: Facilitators Guide
SessionOne/PartThreeYoumentiontoMrs.Montoyathatyounoticedinherchartthatshehasahistoryofhypertensionaswellaselevatedcholesterol.
Yes,Imjustliketherestofmyfamily.SometimesIeattoowell.YoualsofindinherchartthatMrs.MontoyahadapositivePPDtestandnormalchestx-raywhensheimmigratedtotheUnitedStatesfromElSalvadorover30yearsago,butshesaysthatshehasneverhadtuberculosis.Youcontinueyourhistoryandfinallyaskifsheandherhusbandhavesexualrelations,shesmiles,looksawayandsays,Imtoooldforthat.YouaskMrs.Montoyatochangeintoagownandtellherthatthemedicalstudentwillbeintoexamineherandtoaskfurtherquestions.Yougoouttopresenttotheclinicnurseandattendingphysician:Mrs.Montoyapresentstodayconcernedaboutbreastcancer.Shemissedherlastmammogramandisconcernedtodaybecauseafriendwasrecentlydiagnosedwithbreastcancer.Herlastmammogramwasapproximatelythreeyearsago.Shereportsnobreastpain,nippledischarge,ordimpling.Herobstetricalandgynecologicalhistoryissignificantfortwouncomplicatedvaginalbirths.Herperiodsstoppedwhenshehadanabdominalhysterectomyforsymptomaticfibroidsatage46.Shetookoralestrogenafterherhysterectomybutstatesoneofherdoctorstookheroffitacoupleofyearsago.Shehasnothadanyothersurgery.Shehasneverhadanabnormalpapsmear.Shehasapastmedicalhistoryofhypertensionandhighcholesterol.Hermedicationsincludecaptopril25mgthreetimesdaily,hydrochlorothiazide25mgperday,pravastatin40mg
perday,andalbuterolasneeded.Shetakesnocomplementaryoralternativemedicines.Shedeniesanyallergies.Shereportsthatshedoesntdrinkalcoholoruseanydrugs.Herphysicalactivityconsistsofdailywalkstotheparkwithhergrandson.Shereportsanincreaseintirednessoverthepastfewweeksandsomeshortnessofbreathwhileplayingwithhergrandsonatthepark.You,themedicalstudentandyourattendingentertheroomtoperformthephysicalexamtogether.KeyExercisePriortoproceedingontothephysicalexaminformation,askthestudentswhat
informationinthissectionisrelevant?WhatareyoumostworriedaboutinMrs.Montoya?LearnerPrompts/SuggestedTopics
Shortnessofbreathonexertion Hypertension Hypercholesterolemia Medicationreview
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Assessmentoflevelofstressandcopingskills,tangibleproviderquestionstoask,statementstomake
Understandingpatientshealthbeliefsandtheculturalissuesthatareweavedintothesebeliefs
Reviewcasepresentationtotheattending:whatkeyelement/sweremissing
Reviewpatientperceptionsoftheroleofthenurseandtheauthorityoftherolearethereculturaldifferencesinthewayanindividualrelatestoandperceivesthenurse?
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SessionOne/PartFourPhysicalExam:
General:Alertwell-appearingLatinawomaninnoapparentdistress
Height:160cm/64in;Weight80Kg BP:144/90mmHg HR:90bpm Temperature:98.2degreesFahrenheit Respirations:16perminute Oxygensaturation(roomair):98% Head:Normocephalic,atraumatic Eyes:Normalfundiscopicexam Neck:Nothyromegalyorlymphadenopathy.NocarotidbruitsorJVD Chest:Cleartoauscultation Cor:NormalJVP.Non-displacedPMI.Regularrhythm.NormalS1,S2.NoS3,
S4.Nomurmurorrub. Breasts:Symmetric.Non-tender.Noskindimplingwitharmmovements.No
mass.Noaxillaryadenopathy. Abdomen:Normoactivebowelssounds.Non-tender.Nohepatosplenomegaly.
Nomass.Pfannenstielskinscar.Waist41inches. Extremities:Nocyanosis,clubbingoredema.Normalpulses. Neuro:Non-focal.Normalcranialnerveexam.Normalsensoryexam.Normal
DTRs. Pelvic:Normalexternalgenitalia.Absentcervixanduterus.Nopelvictenderness
ormass. Musculoskeletal:Normalrangeofmotion
PsychosocialExam: Primarywrittenandspokenlanguage:Spanish Educationlevel:Completedthe10thgrade Supportsystem:Twodaughters,bothmarried,liveclosetothepatientandsee
heroften,closetothreesistersandseveralgoodfemalefriends,husband Familystructure:Extendedfamilyimportantinsupportanddecisionmaking Healthinsurance/Prescriptionplan:HealthMaintenanceOrganization(HMO)
planthroughhusbandswork,prescriptionscoveredbutwith$15monthlyco-paymentforgenericdrugsand$25monthlyco-paymentforbrandnamedrugs
Profession/workstatus:Notworkingoutsidethehome
Leisuretimeactivities:Attendschurchtwotothreetimesweekly Perceivedlevelofhealth,illness,stress:Rateshealthasfairbecauseof
fatigue,asthma,overweight,doesnotperceiveherselfasill,notesmoderatestressbecauseofillnessoffriendandchildcareresponsibilities
Levelofstressassessment:Moderate
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SessionOne/PartFiveWhileyou,themedicalstudent,andyourattendingarewaitingforthepatienttogetdressed,youdiscussthecase.Yourattendingasksyouwhatscreeningordiagnostic
testsareindicatedinMrs.Montoya.ShealsoaskswhatpatienteducationinformationyouthinkMrs.Montoyamightfinduseful.Youallreturntotheroomtodiscusstheplanofcarewiththepatient.AfterdiscussingMrs.Montoyasconcernsaboutbreastcancer,theattendingasksyoutoreviewwithMrs.Montoyathetestingshehasorderedandtoscheduleafollow-upvisitforherinacoupleofweeks.Aftercompletingthis,youaskMrs.Montoyaifshehasafewminuteswhilesheisheretodiscusshowlifestylechoicesandweightstatusinfluenceherbloodpressuremeasurementsaswellasotherhealthoutcomes.OK,Ihavesometimesincemydaughterdidtakeoffworktoday.Uponleavingtheclinic,Mrs.Montoyatellsyouthatshewillkeepadietarylogasyouhaverecommendedandwillbringitwithheronherreturnappointment.HopefullyIwillhavelost5lbs.too.ImnotsurethatIcanaffordtobuyabloodpressuremachineforhome,isitabsolutelynecessary?KeyExercisePriortoproceedingontoSessionTwoHavethestudentsconsiderwhatdiagnosticteststoorderforMrs.Montoyaatthispointinhercare/evaluation.Havethestudentsindicatetherationaleforalltestsordered.LearnerPrompts/SuggestedTopics
Diagnostictesting Education
o Assessmentofneedso Teachingtechniqueso Stateoflearnerreadinesschangetheoryo Impactofrespect,perceivedpower(bypatient)ofhealthcareprovideras
disseminatorofhealthrecommendations,information,culturaldifferencesinperceptionofhierarchicalpowerinhealthcare
o Impactoflifestylechangesspecifictoweightmanagement,hypertensiono DASHeatingplano Culturaldietdifferences,resourcesfordietrecommendations(for
example,theFoodPyramidfordifferentethnicities)o Homebloodpressuremonitoringfunctionaluseofhomemonitoring
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SessionTwo/PartSixYouareintheoutpatientclinicwhenMrs.Montoyareturnsforherfollow-upvisit.Yougointoseehowshehasbeen.
Well,myfriendtalkedtoherdoctor.Itlooksliketheygotallthecancer.Ihadmymammogramlikethedoctorasked.Whenyouaskaboutherfatiguesheshrugsandsays,Itsthesameasbefore.YouassureMrs.Montoyathatbothhermammogramandclinicalbreastexamwerenormal.Shesighswithrelief.Theneverythingisfine.YoutellMrs.Montoyathatthedoctorhassomeotherconcernsandwillbeintoreviewherlabresultswithher.Youalsoaskifshebroughtherdietarylogwithhertoday.Idid.IdidntrealizehowmuchIsnackwithmygrandsonthroughouttheday.BeforeleavingtheroomyoutakeMrs.Montoyasbloodpressureandgetareadingof138/90.Shetellsyoushehasnotpurchasedabloodpressuremonitorforhomeuse.Whilewaitingforthephysicianyoutakethistimetoreviewherelevatedbloodpressurereadinganddiscusshowfoodchoicescanimpactbloodpressurecontrol.KeyExercise
Askthestudentswhatlabsmightthephysicianhaveorderedorwhatlabresultsaretheymostinterestedin?IsthereanythingelsetheywouldliketodoorshouldreviewwithMrs.Montoya?LearnerPrompts/SuggestedTopics
Weightloss/managementstrategies Laboratoryanddiagnosticresultsreview
o Givingspecificinformationofresults(makingacomparisonofnormalresultstopatientresults,andhowtoconveytheinformationinthecontextofguidelines)
o NCEPcholesterolguidelines
o Secondarycausesofhypercholesteremiao Metabolicsyndromecriteriao Diabetescriteriao Kidneyfunction
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SessionTwo/PartSeven(Givetostudentonlywhenthespecifictestsarerequested)LabResults
Laboratoryresults(fasting): Normalrange
WBC 8.3 3.4-10Hemoglobin 13 1215.5Hematocrit 38.3 36-46Platelets 228 140-450Iron Notordered Ferritin Notordered Electrolytes Normal BUN Notordered Creatinine 1.0 0.61.2Glucose 120 70-109HemoglobinA1C 7.4 4.86.7LiverFunctiontests Normal Cholesterol 224
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Tutors:
Studentsrequest:
NOECG,NOstresstest ENDINGONE
ECG,NOcardiacstresstest ENDINGONE
Stresstest(mustgiverationale) ENDINGTWO
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SessionTwo(EndingOne)/PartEightYoureassureMrs.MontoyathatthedoctorbelievesherECGisnormal.However,shehassuggestedsomechangestohermedications.Youexplainthattheattendingwould
liketoincreaseherpravastatinto80mgperdaysinceherLDLcholesterolisstillhigherthantheywouldliketoseeit.Inaddition,afluticasoneinhalerhasbeenprescribedforherasthma.Youtellherthatthedoctorwouldlikeforhertoreturninthreemonthssothatherbloodpressurecanberecheckedandherresponsetothechangeincholesterolmedicationscanbeevaluated.Youremindherthatherbloodpressureisstillhigherthannormalandaskherifsheistakingherdailybloodpressurepillsorifsheusinganythingelsetotryandmanageherbloodpressure.Well,Istartedgarlicabout4weeksagoandIranoutofmyonepill,Ijustdidnthavetimetogotothepharmacy.Youreview,discussandplanhealthierfoodchoiceswithMrs.Montoyabasedonthedietarylogshebroughtwithher.Mutuallyagreedupongoalsanddietarychangesareset.YoutellMrs.Montoyatogotothepharmacytogethercaptoprilprescriptionfilledandtostarttakingthepilleverydayagain.Youtellherthatonherreturnvisitinthreemonths,youwillreviewherprogressandsuccesswiththeagreedupondietarychangesandgoalweightloss.Inaddition,youtellMrs.Montoyatocallyouwithanyquestionsorconcernsandencouragehertofocusonhealthylivingandchoices.KeyExercisesWhatarethenursingcareopportunitiesinthissession?WhatinformationwouldthenursehavegiventoMrs.Montoyaaboutherdiet,medicationsorothertopic?Arethereareasinthissessionthatmightrequireknowledgeaboutmanagement/treatment
guidelines?LearnerPrompts/SuggestedTopics
Behaviorchangetheory
Possiblereasonsforfailedbloodpressuretreatmento Medicationrelatedo Behaviorrelatedo Culturallyrelated
Waystocommunicatetheimportanceoftakingmedicationsasprescribed
Othereducationalopportunitieso Signsandsymptomsofmyocardialinfarctiono Exerciseprescriptiono Treatmentmanagementgoals
LDLcholesterolgoalBPgoalWeightgoalExercisegoalServingsoffish,fruit,vegetables,wholegraingoals
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SessionTwo(EndingOne)/PartNineTwomonthslater,youareintheEmergencyDepartment(ED)doingyourclinicalrotationandMrs.Montoyaisbroughtinbyambulanceaftersufferingamyocardial
infarction.Herhusbandanddaughteraccompanyhertothehospital,whiletherestofthefamilywaitsathomefornews.AlthoughMrs.Montoyareceivescardiacresuscitation,sheispronounceddeadsoonafterarrivingattheED.YouaccompanytheEDphysicianwhenshegoestospeaktothefamily;theyareclearlyagitatedandworriedwhentheyseethetwoofyouapproaching.ThephysiciantakesthefamilyasideandexplainsthatMrs.Montoyahashadaheartattackandalthougheverythingwasdonetosaveherlife,theywerenotabletosaveher.Herdaughterbreaksintotearsandhugsherfather,whoalsobeginstocry.Herchestdidnthurttoday,shejustsaidshefeltfunnyandlaiddownonthecouchandIcouldntgetherup,criedherdaughter.Shefeltok,justtired.Shewaswatchingmysontoday,maybeshechasedafterhimtoomuch.Ishouldnthavelefthimwithhereveryday,itwastoomuchforher!Theattendingreassuresthefamily.Therewasnothingyoucouldhavedone;itwasntyourfaultthatyourmotherhadaheartattack.YoucouldnthaveseenthiscomingandgottenhertotheEDanysoonertosaveherlife.Afteryouleavethefamily,youtellyourattendingthatyousawMrs.Montoyainclinicafewmonthsagoandaskwhatyoucouldhavedonedifferently.Theattendingexplainsthat,likemen,womenwithheartdiseasemostcommonlypresentwithchestpainordiscomfort.But,womenaremorelikelythanmentoexperiencesomeoftheother
commonsymptoms,suchasshortnessofbreath.Mrs.Montoyasdyspneaandchestdiscomfortmighthavebeenacluethatshewassufferingfromheartdisease.ArestingECGcansometimesbenormalevenwhenseverecardiacdiseaseispresent,soarestingECGcannotbeusedtoexcludeapossiblediagnosisofcardiacdisease.Thenextstudyforthepatientwouldhavebeenatypeofstresstest.Stresstestsincludeexercisetreadmilltests,exerciseimagingtestsandpharmacologicstressimagingtests.Ifshecouldexercise,anexercisestresstestwouldhavebeenbest,butbecauseofherasthma,Ithinkapharmacologicstresstestlikeadobutamineechocardiogramwouldhavebeenagoodchoice.Theresultsofthetestcouldhavetoldyoutherewasablockage,and,ifso,whatfurthertreatmentmightbeneeded.
Youaskaboutthepatientandfamilysdescriptionofherfatigue.CouldthathavebeenaclueforherriskforMI?Theattendingpointsoutthatsomeliteraturesuggeststhatunusualfatiguemaybeasignofimpendinginfarction.Sheemphasizesthatitisalwaysimportanttotakeafurtherhistoryandreviewofsystemswhenpatientspresentwithfatigue.
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YouthinkbackoverMrs.MontoyascaseandrealizethatshehadsignificantcardiacriskfactorsandyourealizethatfromthisexperienceandthegriefyoufeeloverherlossthatyouwontmissthosesignsagainwhenyouseeapatientlikeMrs.Montoya.
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SessionTwo(EndingTwo)/PartEightAfterreviewinghertests,thephysicianexplainstoMrs.Montoyathatgivenherrisk
factorsforcardiacdisease,fatigue,andexertionaldyspneaandchestheaviness,shewouldliketodoanECGintheofficetodayandcallthehospitaltoscheduleastresstestofherheart.Idontthinkanythingiswrongwithmyheart,Idonthaveanypaininmychest,Mrs.Montoyareplies.Theattendingexplainsthat,likemen,womenwithheartdiseasemostcommonlypresentwithchestpainordiscomfort.But,womenaremorelikelythanmentoexperiencesomeoftheothercommonsymptoms,suchasshortnessofbreath.Feelingshortofbreathoradifferentsensationinthechest,neck,jaw,orabdomen,particularlywithexertionoremotionalstress,canbeasignofheartdisease.Shegoesontotellherthatthestressinstresstestreferstoexerciseormedicationthatincreasesherheartrate.Thetestitselfwillbeanultrasound(echocardiogram)ornuclearmedicinestudytolookattheheart.Becauseherasthmarestrictsherabilitytoexercise,theattendingrecommendsadobutaminestresstest.Thephysicianleavestheroomtocallthestresslabatthehospital;yousitdownwithMrs.Montoyatohelpherunderstandherindividualriskfactorsforcardiovasculardiseaseandprocesswithherthecomplaintsofpersistentfatigueandshortnessofbreathandhowthisisworrisometothehealthcareteam.
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SessionTwo(EndingTwo)/PartNineDobutamineStressToleranceTest:
Resting: NormalSinusRhythmDobutamineinfusion:Symptoms:NoneBloodPressure:Increasedfrom160/102to194/104HeartRate:Increasedfrom86to154bpmECGfindings: STelevationinV4-V6,II,andAVFatpeakheartrate.Recovery: ResolutionofSTchangesConclusion: TherewasECGevidenceofstress-inducedischemia.Thisisapositivetest.Mrs.Montoyareturnstotheofficewithherhusband,followingthestresstest.Youandthephysiciansitdowntoexplaintheresultstoher.Youinformherthatbecauseherstresstestwasquiteabnormal,sheneedstoundergocardiaccatheterization.Sheandherhusbandappearconcernedwhenyouexplainthisproceduretoher.Canmyhusbandormydaughterbewithmeduringthetest?Youexplainthattheycanaccompanyhertothehospitalbutwillhavetowaitinthewaitingroomduringtheprocedure.Thephysiciangoesontoexplainthatthetestisquiteroutineandgenerallyquitesafe,butveryhelpfulinprovidingcrucialdataonherheart.Mr.Montoyaquietlyasks,
Arethereanyrisksfromhavingthetest?Itsoundsprettydangeroustome.Thephysicianexplainstheprocedureandtherisksandbenefits.Sheexplainsthatthereisaboutaoneinathousandchanceofmajorcomplicationssuchasastrokeorheartattackasaresultoftheprocedure.Mr.Montoyaseemsskepticalabouttheapprovingtheprocedurewhilethephysiciancontinuestoexplainthebenefitsofknowingifthereisablockage.Ifthereisablockageandwedontdetectitintime,yourwifecouldhaveaheartattack.Sothebenefitsoftheprocedureoutweightherisksofit.Whenyougofortheprocedure,thecardiologistwillexplaintherisksandbenefitsinmoredetail.
Thefollowingweek,Mrs.Montoyaundergoescardiaccatheterizationthatrevealsadiffuselydiseasedleftanteriordescendingartery,arightdominantsystemwithseverestenoticlesionsandaleftventricularejectionfractionof55%.Twoweekslater,Mrs.Montoyaundergoesafour-vesselcoronaryarterybypassgraftsurgery,whileherentirefamilywaitsanxiouslyinthewaitingroom.Mrs.Montoyasdaughter-in-lawhelpsoutbywatchingRobertathome.Mrs.Montoyaexperiencesnocomplications.Shespendsthefirstdayintheintensivecareunit,andthentransfersto
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asurgicalwardwhereherfamilyvisitsherthroughoutherstayinthehospital.Sheisdischargedingoodconditiononalow-saturatedfat,lowcholesteroldietwithplanforcardiacrehabilitationafterthepost-oprecoveryperiod.Sixmonthslaterasyouwalkfromthehospitaltotheoutpatientclinic,youseeMrs.
Montoyaandaskherhowshesdoing.Ifeelgreat.Robertisasenergeticasever,butIdontfeelastiredasIusedtofeelevenafterspendingthedaychasingafterhimandImnotshortofbreathanymore.Mydaughterisworking80%nowandstayshomewithRobertonedayaweek.Theyallworryaboutmetoomuch.Imfine.Ijusthavetotrytostayonmydiet.Thatsthehardestthing.Youwishhergoodluckandgoofftoclinic.SuggestedLearningIssues
ListthemajorknownCVDrisks,identifygenderandracialdifferencesintherelativeimportanceofthevariousriskfactorsandreferencecurrentnationalguidelinesforriskfactormanagement.Specifically:
o Hypertension
Summarizecurrentnationalguidelinesonbloodpressuremonitoring,treatmentandcontrolDescribetheimpactofhypertensiononCVDrisk
o Hyperlipidemia
Summarizecurrentnationalguidelinesonlipidscreeninganddescribethegoalsforoptimallevelsofallindices(TC,LDL,HDL,TriglyceridesandTC/HDLratio)DescribetheimpactofhyperlipidemiaonCVDriskandtheimpactoflipidloweringonCVDrisk
o DiabetesMellitus(DM)
DescribetheimpactofDMonCVDriskandtheimpactofgoodcontrolofglucoseonCVDriskIdentifyDMasaCVDriskequivalentDiscussmetabolicsyndromeandcurrentcriteriafordiagnosis
o Smoking
SummarizesmokingstatisticsandtrendsintheUnitedStatesDescribetheimpactoftobaccoabuseonCVDrisk
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o Sedentarylifestyle
SummarizephysicalactivitytrendsandstatisticsintheUnitedStates
IdentifycommonbarriersthatinterferewithawomansdailyphysicalactivityIdentifygenderdifferencesinadultphysicalactivitylevels
o Obesity
SummarizeobesityepidemiologyandobesitytrendsintheUnitedStatesSummarizecurrentnationalguidelines,includingSurgeonGeneralsrecommendationsonevaluationofweightstatusandmanagementstrategies/goalsIdentifyinfluencesonawomansweighthistory
Stress
Depression
o Depression
Summarizegenderdifferencesintrends/statisticsforstressanddepression
DescribetheimpactofdepressiononCVDrisk
o FamilyhistoryofMI/stroke
Describetheimpactof+/-familyhistoryonCVDrisk
SummarizecurrentstateofknowledgeofgeneticsinrelationtoCVD
o DefineriskstratificationconceptsandapplythesetoCVDrisk
IdentifythekeycomponentsoftheFraminghamriskscale/score.
o Identifyevidence-basedpatienteducationalresourcesforprimarypreventionofheartdisease,treatmentofheartdiseaseandsecondarypreventionofheartdisease.
o SummarizethecurrentstateofknowledgeofmenopauseandhormonetherapyanditsaffectonawomansriskfordevelopingCVD
o Discusslifestyleinterventions
SmokingCessationo Summarizecurrentknowledgeofcessationoptions
andkeymessagestobeconveyedtowomen
PhysicalActivityo Summarizenationalphysicalactivityguidelinesthat
addressmaintaininghealth
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Diet(includingOmega3fattyacidsandfolicacid)
o Summarizethecurrentstateofknowledgeofthefood,mineralandvitamincomponentsnecessaryfora
hearthealthydieto Summarizecurrentnationalguidelinesforahearthealthydiet
o DescribetheMediterraneandietandbenefitsofthisdiet
o SummarizecurrentfaddietsandhowthesedietsimpactCVD
WeightManagemento Summarizecurrentnationalguidelines,Surgeon
Generalsrecommendationsonweightlossmanagementstrategies/goals
o Identifybarriersthatinterferewithaweightlossplano Psychosocial
StressManagemento Describetheoptionsavailableforstressreduction
techniqueso Describethelatesttreatmentsforanxietyand
depression
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The Case of Mrs. Montoya:Nursing Problem-based Learning CaseStudent Materials
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The Case of Mrs. Montoya
SessionOne/PartOneTodayaspartofyourclinicalrotation,youareintheoutpatientclinic.Yournursing
instructorasksyoutobeinvolvedinthecareofMs.AmparoMontoya,a58year-oldLatinawomanwhoisareturningpatienttoclinic.Youentertheroomandaskwhatbringshertoclinictoday.Shetellsyouthatherclosefriendhasbeendiagnosedwithbreastcancerandnowsheisworriedtoo.Icantfeelalumprightnow,butneitherdidshe.Shethinksherlastmammogramwastwoorthreeyearsago.Yousee,Itakecareofmylittlegrandson,Robert,becausemydaughterandherhusbandbothworkandifIhavetocometothedoctor,mydaughterhastostayhometotakecareofhim.Iwanttohelpher,notbeaburdentoher.TodayshetookoffacoupleofhourssoIcouldcomein.Imsoworried,myfriendjusthadsurgeryandshesstartedchemo.Imsoworriedaboutthecaresheisgoingtoreceive.ShedoesntspeakEnglish.Thechemonursescantfindaninterpreter.Shessotired.Igettiredsometimestoo.IthinkitsjustbecauseRobertissuchabusyboy!Hestwoandhehaslotsofenergy!Butwhatifitscancer?Itakecareofmyfamily,Icantaffordtobesick,toomanypeoplecountonme.Youacknowledgeherfamilialresponsibilities;herconcernforherfriendaswellastheconcernforherownhealthandaskherCanyoutellmeaboutyourlastmammogramvisit?Howwasthatexperience?Imcuriousastowhyyouvenotbeenback.
NotgoodMrs.Montoyareplies.Ididntwanttogobacktherebecauseofconfusionwithmyinsurance,ittooksolongandIhadtogetbacktoRobertandIheardonthenewsthatannualmammogramsmightnotbeneeded.
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SessionOne/PartTwoYouassureMrs.Montoyathatyouwilldiscussherbreasthealthconcernswiththephysician,butthatyouwouldliketoaskafewquestionsfirst.Youtellherthatyou
understandthewordfatiguecanmeanmanydifferentthingstomanydifferentpeopleindifferentculturesandaskherWhatdoesbeingfatiguedmeantoyou?Shetellsyouthatshehasfeltabitmoretiredforthepastfewweeks.Youaskhertoexplainhertirednessmore.BesideschasingafterRobertallday,maybeitsbecauseIdontsleepverywell.Iwakeupatfourorfiveinthemorningandcantgetbacktosleep.Shenoticesmildshortnessofbreathwhenplayingwithhimatthepark,whichsheattributestoherasthma.Shehasahistoryofmildasthmasincechildhoodandoccasionallyusesanalbuterolinhaler.Shehasnevertakensteroidsforherasthma.Shereportsthatsheneverhasshortnessofbreathwhileatrestandhasneverexperiencedanychestpain.Shereportsthatalthoughsheneverseemstogetenoughsleep,shestillhasenergytocookforherfamily,dotheshopping,andkeepupthehouse.YoufindthatMs.Montoyadoesnothavebreastpain;shehasnotnoticedanydischargefromhernipples,anydimpling,oranyotherchangestoherbreasts.Shedoesntusuallydoamonthlybreastexamsoshesnotsureifsheshadanybreastlumpsinthepastornot.Idontthinkanyoneinmyfamilyhashadbreastcancer,notthatIknowof.Myunclehadlungcancer,buthesmokedalotafterhemovedtothiscountry.Otherwise,myfamilyisprettyhealthynowexceptbothmyparentshavehighbloodpressure.Myfather
hadaheartattackabout15yearsagowhenhewas61.ThatswhentheymovedinwithmysisterinElSalvador.Iworryaboutthemallthetime,butImsuremysisteristakinggoodcareofthem.Hehadtohavesurgeryforhisheartbackthen,buthesdoingoknow.Mymomandbrotherhavediabetes,buttheyremostlyoktoo,theytrytoeatbetter,butitshard.Itrytocookthethingsthedoctorsaidtomake,but.Sheshrugs.Mytwoyoungersistersandmychildrenareveryhealthynodiabetes,nohighbloodpressure,nocancer.Myhusbandtakesmedicationeverydayforhighbloodpressuretooandhetakesanaspirinforhisheart.Iworryhellhaveaheartattacklikemyfather;heworkstoohard.Shehashadnochangesinherweight.Shereportsthatherappetiteisfair,butthatshe
sometimesjustdoesntfeellikeeating.Youaskabouthermoodandshestatessheworriesalotaboutherfamily.Herdaughterandson-in-lawlivenearbyandshetakescareofhergrandsonfull-time.Youaskherifshehaseverhadanypressureordiscomfortinherchest.Shereplies,SometimeswhenImplayingintheparkwithmygrandson.
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Shesaysthatshedoesnothaveacough,althoughherson-in-lawsmokes.Neithershenorherhusbandsmokeandsheonlyallowsherson-in-lawtosmokeoutdoors.
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SessionOne/PartThreeYoumentiontoMrs.Montoyathatyounoticedinherchartthatshehasahistoryofhypertensionaswellaselevatedcholesterol.
Yes,Imjustliketherestofmyfamily.SometimesIeattoowell.YoualsofindinherchartthatMrs.MontoyahadapositivePPDtestandnormalchestx-raywhensheimmigratedtotheUnitedStatesfromElSalvadorover30yearsago,butshesaysthatshehasneverhadtuberculosis.Youcontinueyourhistoryandfinallyaskifsheandherhusbandhavesexualrelations,shesmiles,looksawayandsays,Imtoooldforthat.YouaskMrs.Montoyatochangeintoagownandtellherthatthemedicalstudentwillbeintoexamineherandtoaskfurtherquestions.Yougoouttopresenttotheclinicnurseandattendingphysician:Mrs.Montoyapresentstodayconcernedaboutbreastcancer.Shemissedherlastmammogramandisconcernedtodaybecauseafriendwasrecentlydiagnosedwithbreastcancer.Herlastmammogramwasapproximatelythreeyearsago.Shereportsnobreastpain,nippledischarge,ordimpling.HerOb/Gynhistoryissignificantfortwouncomplicatedvaginalbirths.Herperiodsstoppedwhenshehadanabdominalhysterectomyforsymptomaticfibroidsatage46.Shetookoralestrogenafterherhysterectomybutstatesoneofherdoctorstookheroffitacoupleofyearsago.Shehasnothadanyothersurgery.Shehasneverhadanabnormalpapsmear.Shehasapastmedicalhistoryofhypertensionandhighcholesterol.Hermedicationsincludecaptopril25mgthreetimesdaily,hydrochlorothiazide25mgperday,pravastatin40mgperday,
andalbuterolasneeded.Shetakesnocomplementaryoralternativemedicines.Shedeniesanyallergies.Shereportsthatshedoesntdrinkalcoholoruseanydrugs.Herphysicalactivityconsistsofdailywalkstotheparkwithhergrandson.Shereportsanincreaseintirednessoverthepastfewweeksandsomeshortnessofbreathwhileplayingwithhergrandsonatthepark.You,themedicalstudentandyourattendingentertheroomtoperformthephysicalexamtogether.
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The Case of Mrs. Montoya
SessionOne/PartFourPhysicalExam:
General:Alertwell-appearingLatinawomaninnoapparentdistress Height:160cm/64in;Weight80Kg
BP:144/90mmHg HR:90bpm Temperature:98.2degreesFahrenheit Respirations:16perminute Oxygensaturation(roomair):98% Head:Normocephalic,atraumatic Eyes:Normalfundiscopicexam Neck:Nothyromegalyorlymphadenopathy.NocarotidbruitsorJVD Chest:Cleartoauscultation Cor:NormalJVP.Non-displacedPMI.Regularrhythm.NormalS1,S2.NoS3,
S4.Nomurmurorrub. Breasts:Symmetric.Non-tender.Noskindimplingwitharmmovements.No
mass.Noaxillaryadenopathy. Abdomen:Normoactivebowelssounds.Non-tender.Nohepatosplenomegaly.
Nomass.Pfannenstielskinscar.Waist41inches. Extremities:Nocyanosis,clubbingoredema.Normalpulses. Neuro:Non-focal.Normalcranialnerveexam.Normalsensoryexam.Normal
DTRs. Pelvic:Normalexternalgenitalia.Absentcervixanduterus.Nopelvictenderness
ormass. Musculoskeletal:Normalrangeofmotion
PsychosocialExam: Primarywrittenandspokenlanguage:Spanish Educationlevel:Completedthe10thgrade Supportsystem:Twodaughters,bothmarried,liveclosetothepatientandsee
heroften,closetothreesistersandseveralgoodfemalefriends,husband Familystructure:Extendedfamilyimportantinsupportanddecisionmaking Healthinsurance/Prescriptionplan:HealthMaintenanceOrganization(HMO)
planthroughhusbandswork,prescriptionscoveredbutwith$15monthlyco-paymentforgenericdrugsand$25monthlyco-paymentforbrandnamedrugs
Profession/workstatus:Notworkingoutsidethehome Leisuretimeactivities:Attendschurchtwotothreetimesweekly
Perceivedlevelofhealth,illness,stress:Rateshealthasfairbecauseoffatigue,asthma,overweight,doesnotperceiveherselfasill,notesmoderatestressbecauseofillnessoffriendandchildcareresponsibilities
Levelofstressassessment:Moderate
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The Case of Mrs. Montoya
SessionOne/PartFiveWhileyou,themedicalstudent,andyourattendingarewaitingforthepatienttogetdressed,youdiscussthecase.Yourattendingasksyouwhatscreeningordiagnostic
testsareindicatedinMrs.Montoya.ShealsoaskswhatpatienteducationinformationyouthinkMrs.Montoyamightfinduseful.Youallreturntotheroomtodiscusstheplanofcarewiththepatient.AfterdiscussingMrs.Montoyasconcernsaboutbreastcancer,theattendingasksyoutoreviewwithMrs.Montoyathetestingshehasorderedandtoscheduleafollow-upvisitforherinacoupleofweeks.Aftercompletingthis,youaskMrs.Montoyaifshehasafewminuteswhilesheisheretodiscusshowlifestylechoicesandweightstatusinfluenceherbloodpressuremeasurementsaswellasotherhealthoutcomes.OK,Ihaveasometimesincemydaughterdidtakeoffworktoday.Uponleavingtheclinic,Mrs.Montoyatellsyouthatshewillkeepadietarylogasyouhaverecommendedandwillbringitwithheronherreturnappointment.HopefullyIwillhavelost5lbs.too.ImnotsurethatIcanaffordtobuyabloodpressuremachineforhome,isitabsolutelynecessary?
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The Case of Mrs. Montoya
SessionTwo/PartSixYouareintheoutpatientclinicwhenMrs.Montoyareturnsforherfollow-upvisit.Yougointoseehowshehasbeen.
Well,myfriendtalkedtoherdoctor.Itlooksliketheygotallthecancer.Ihadmymammogramlikethedoctorasked.Whenyouaskaboutherfatiguesheshrugsandsays,Itsthesameasbefore.YouassureMrs.Montoyathatbothhermammogramandclinicalbreastexamwerenormal.Shesighswithrelief.Theneverythingisfine.YoutellMrs.Montoyathatthedoctorhassomeotherconcernsandwillbeintoreviewherlabresultswithher.Youalsoaskifshebroughtherdietarylogwithhertoday.Idid.IdidntrealizehowmuchIsnackwithmygrandsonthroughouttheday.BeforeleavingtheroomyoutakeMrs.Montoyasbloodpressureandgetareadingof138/90.Shetellsyoushehasnotpurchasedabloodpressuremonitorforhomeuse.Whilewaitingforthephysicianyoutakethistimetoreviewherelevatedbloodpressurereadinganddiscusshowfoodchoicescanimpactbloodpressurecontrol.
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The Case of Mrs. Montoya
SessionTwo(EndingOne)/PartEightYoureassureMrs.MontoyathatthedoctorbelievesherECGisnormal.However,shehassuggestedsomechangestohermedications.Youexplainthattheattendingwouldliketoincreaseherpravastatinto80mgperdaysinceherLDLcholesterolisstillhigher
thantheywouldliketoseeit.Inaddition,afluticasoneinhalerhasbeenprescribedforherasthma.Youtellherthatthedoctorwouldlikeforhertoreturninthreemonthssothatherbloodpressurecanberecheckedandherresponsetothechangeincholesterolmedicationscanbeevaluated.Youremindherthatherbloodpressureisstillhigherthannormalandaskherifsheistakingherdailybloodpressurepillsorifsheusinganythingelsetotryandmanageherbloodpressure.Well,Istartedgarlicabout4weeksagoandIranoutofmyonepill,Ijustdidnthavetimetogotothepharmacy.Youreview,discussandplanhealthierfoodchoiceswithMrs.Montoyabasedonthedietarylogshebroughtwithher.Mutuallyagreedupongoalsanddietarychangesareset.YoutellMrs.Montoyatogotothepharmacytogethercaptoprilprescriptionfilledandtostarttakingthepilleverydayagain.Youtellherthatonherreturnvisitinthreemonths,youwillreviewherprogressandsuccesswiththeagreedupondietarychangesandgoalweightloss.Inaddition,youtellMrs.Montoyatocallyouwithanyquestionsorconcernsandencouragehertofocusonhealthylivingandchoices.
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The Case of Mrs. Montoya
SessionTwo(EndingOne)/PartNineTwomonthslater,youareintheEmergencyDepartment(ED)doingyourclinicalrotationandMrs.Montoyaisbroughtinbyambulanceaftersufferingamyocardial
infarction.Herhusbandanddaughteraccompanyhertothehospital,whiletherestofthefamilywaitsathomefornews.AlthoughMrs.Montoyareceivescardiacresuscitation,sheispronounceddeadsoonafterarrivingattheED.YouaccompanytheEDphysicianwhenshegoestospeaktothefamily;theyareclearlyagitatedandworriedwhentheyseethetwoofyouapproaching.ThephysiciantakesthefamilyasideandexplainsthatMrs.Montoyahashadaheartattackandalthougheverythingwasdonetosaveherlife,theywerenotabletosaveher.Herdaughterbreaksintotearsandhugsherfather,whoalsobeginstocry.Herchestdidnthurttoday,shejustsaidshefeltfunnyandlaiddownonthecouchandIcouldntgetherup,criedherdaughter.Shefeltok,justtired.Shewaswatchingmysontoday,maybeshechasedafterhimtoomuch.Ishouldnthavelefthimwithhereveryday,itwastoomuchforher!Theattendingreassuresthefamily.Therewasnothingyoucouldhavedone;itwasntyourfaultthatyourmotherhadaheartattack.YoucouldnthaveseenthiscomingandgottenhertotheEDanysoonertosaveherlife.Afteryouleavethefamily,youtellyourattendingthatyousawMrs.Montoyainclinicafewmonthsagoandaskwhatyoucouldhavedonedifferently.Theattendingexplainsthat,likemen,womenwithheartdiseasemostcommonlypresentwithchestpainordiscomfort.But,womenaremorelikelythanmentoexperiencesomeoftheother
commonsymptoms,suchasshortnessofbreath.Mrs.Montoyasdyspneaandchestdiscomfortmighthavebeenacluethatshewassufferingfromheartdisease.ArestingECGcansometimesbenormalevenwhenseverecardiacdiseaseispresent,soarestingECGcannotbeusedtoexcludeapossiblediagnosisofcardiacdisease.Thenextstudyforthepatientwouldhavebeenatypeofstresstest.Stresstestsincludeexercisetreadmilltests,exerciseimagingtestsandpharmacologicstressimagingtests.Ifshecouldexercise,anexercisestresstestwouldhavebeenbest,butbecauseofherasthma,Ithinkapharmacologicstresstestlikeadobutamineechocardiogramwouldhavebeenagoodchoice.Theresultsofthetestcouldhavetoldyoutherewasablockage,and,ifso,whatfurthertreatmentmightbeneeded.
Youaskaboutthepatientandfamilysdescriptionofherfatigue.CouldthathavebeenaclueforherriskforMI?Theattendingpointsoutthatsomeliteraturesuggeststhatunusualfatiguemaybeasignofimpendinginfarction.Sheemphasizesthatitisalwaysimportanttotakeafurtherhistoryandreviewofsystemswhenpatientspresentwithfatigue.
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YouthinkbackoverMrs.MontoyascaseandrealizethatshehadsignificantcardiacriskfactorsandyourealizethatfromthisexperienceandthegriefyoufeeloverherlossthatyouwontmissthosesignsagainwhenyouseeapatientlikeMrs.Montoya.
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The Case of Mrs. Montoya
SessionTwo(EndingTwo)/PartEightAfterreviewinghertests,thephysicianexplainstoMrs.Montoyathatgivenherriskfactorsforcardiacdisease,fatigue,andexertionaldyspneaandchestheaviness,shewouldliketodoanECGintheofficetodayandcallthehospitaltoscheduleastresstest
ofherheart.Idontthinkanythingiswrongwithmyheart,Idonthaveanypaininmychest,Mrs.Montoyareplies.Theattendingexplainsthat,likemen,womenwithheartdiseasemostcommonlypresentwithchestpainordiscomfort.But,womenaremorelikelythanmentoexperiencesomeoftheothercommonsymptoms,suchasshortnessofbreath.Feelingshortofbreathoradifferentsensationinthechest,neck,jaw,orabdomen,particularlywithexertionoremotionalstress,canbeasignofheartdisease.Shegoesontotellherthatthestressinstresstestreferstoexerciseormedicationthatincreasesherheartrate.Thetestitselfwillbeanultrasound(echocardiogram)ornuclearmedicinestudytolookattheheart.Becauseherasthmarestrictsherabilitytoexercise,theattendingrecommendsadobutaminestresstest.Thephysicianleavestheroomtocallthestresslabatthehospital;yousitdownwithMrs.Montoyatohelpherunderstandherindividualriskfactorsforcardiovasculardiseaseandprocesswithherthecomplaintsofpersistentfatigueandshortnessofbreathandhowthisisworrisometothehealthcareteam.
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The Case of Mrs. Montoya
SessionTwo(EndingTwo)/PartNineDobutamineStressToleranceTest:
Resting: NormalSinusRhythmDobutamineinfusion:Symptoms:NoneBloodPressure:Increasedfrom160/102to194/104HeartRate:Increasedfrom86to154bpmECGfindings: STelevationinV4-V6,II,andAVFatpeakheartrate.Recovery: ResolutionofSTchangesConclusion: TherewasECGevidenceofstress-inducedischemia.Thisisapositivetest.Mrs.Montoyareturnstotheofficewithherhusband,followingthestresstest.Youandthephysiciansitdowntoexplaintheresultstoher.Youinformherthatbecauseherstresstestwasquiteabnormal,sheneedstoundergocardiaccatheterization.Sheandherhusbandappearconcernedwhenyouexplainthisproceduretoher.Canmyhusbandormydaughterbewithmeduringthetest?Youexplainthattheycanaccompanyhertothehospitalbutwillhavetowaitinthewaitingroomduringtheprocedure.Thephysiciangoesontoexplainthatthetestisquiteroutineandgenerallyquitesafe,butveryhelpfulinprovidingcrucialdataonherheart.Mr.Montoyaquietlyasks,
Arethereanyrisksfromhavingthetest?Itsoundsprettydangeroustome.Thephysicianexplainstheprocedureandtherisksandbenefits.Sheexplainsthatthereisaboutaoneinathousandchanceofmajorcomplicationssuchasastrokeorheartattackasaresultoftheprocedure.Mr.Montoyaseemsskepticalabouttheapprovingtheprocedurewhilethephysiciancontinuestoexplainthebenefitsofknowingifthereisablockage.Ifthereisablockageandwedontdetectitintime,yourwifecouldhaveaheartattack.Sothebenefitsoftheprocedureoutweightherisksofit.Whenyougofortheprocedure,thecardiologistwillexplaintherisksandbenefitsinmoredetail.
Thefollowingweek,Mrs.Montoyaundergoescardiaccatheterizationthatrevealsadiffuselydiseasedleftanteriordescendingartery,arightdominantsystemwithseverestenoticlesionsandaleftventricularejectionfractionof55%.Twoweekslater,Mrs.Montoyaundergoesafour-vesselcoronaryarterybypassgraftsurgery,whileherentirefamilywaitsanxiouslyinthewaitingroom.Mrs.Montoyasdaughter-in-lawhelpsoutbywatchingRobertathome.Mrs.Montoyaexperiencesnocomplications.Shespendsthefirstdayintheintensivecareunit,andthentransfersto
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The Case of Mrs. Montoya
asurgicalwardwhereherfamilyvisitsherthroughoutherstayinthehospital.Sheisdischargedingoodconditiononalow-saturatedfat,lowcholesteroldietwithplanforcardiacrehabilitationafterthepost-oprecoveryperiod.Sixmonthslaterasyouwalkfromthehospitaltotheoutpatientclinic,youseeMrs.
Montoyaandaskherhowshesdoing.Ifeelgreat.Robertisasenergeticasever,butIdontfeelastiredasIusedtofeelevenafterspendingthedaychasingafterhimandImnotshortofbreathanymore.Mydaughterisworking80%nowandstayshomewithRobertonedayaweek.Theyallworryaboutmetoomuch.Imfine.Ijusthavetotrytostayonmydiet.Thatsthehardestthing.Youwishhergoodluckandgoofftoclinic.
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EXAMINATIONQUESTIONS(MultipleChoice)RiskFactorIdentification/Management
Early Learner1. AllofthefollowingareknownmajorriskfactorsforCVDexceptfor:
a. Smallvesselcerebrovasculardiseaseb. Diabetesc. Smokingd. Obesitye. Hypertension
2. Whichriskfactorelevatesawomansriskforheartdiseasebyapproximately6-
fold?a. BMI>25b. Sedentarylifestylec. Hyperlipidemiad. Smokinge. Age>55
3. Whichwomanhasthegreatestriskforheartdiseasebasedonethnicityalone?
a. NativePacificIslanderb. AsianAmericanc. AfricanAmericand. Latinae. Caucasian
4. Currentcomprehensiveguidelinesformanagementofhypertensioncanbefound
inthefollowingreport:a. JNC7b. ATPIIIc. MerckManuald. SurgeonGeneralsAnnualReporte. Alloftheabove
5. Allofthefollowingaremajorlifestylemodificationsshowntolowerblood
pressureEXCEPTfor:
a. Quittingsmokingb. Eliminatingcaffeinec. Quittingworkd. Takingyogaclassese. Noneoftheabove
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6. TheDASHeatingplanisrichinthefollowing:
a. Magnesium&potassiumb. Calciumc. Protein&fiber
d.
OnlyA&Be. Alloftheabove
7. Whichclinicaldisease/condition,accordingtoATPIII,confershighriskforcoronaryheartdisease(CHDRiskEquivalent)?
a. Asthmab. Hypertensionc. Abdominalaorticaneurysmd. Hyperlipidemiae. Depression
8. Whichclinicaldisease/condition,accordingtoATPIII,confershighriskfor
coronaryheartdisease(CHDRiskEquivalent)?a. FamilyHistoryb. Diabetesc. Smokingd. Elevatedhs-CRPe.Morbidobesity
9. BasedonMrs.Montoyaslipidresultsandriskfactorprofile,theATPIII
recommendedapproachtoherdyslipidemiawouldinclude:a. AfibratedrugtoraiseherHDLcholesterolb. Avoidanceofhighcarbohydratedietstolowerhertriglycerides
c. IncreasedalcoholintaketoraiseherHDLcholesterold. Alloftheabovee. Noneoftheabove
10. IfapatienttakingastatinmedicationweretoreduceherLDLcholesterolby20%,
heroverallriskofacardiaceventwoulddecreaseby:a. 10% b. 15%c. 20%d. 25%e. 30%
11.Theprimarytargetforcholesterol-loweringtherapyis:
a. HDLb. Triglyceridesc. LDLd. Totalcholesterole. A&C
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12.Thepresenceofdiabetes:
a. ShouldmodifytreatmentgoalsforLDLcholesterolb. Shouldbetreatedasaseparatecategoryofhigherriskc. ElevatesriskforCVDsubstantiallyd.
Noneoftheabovee. Alloftheabove
13.Womenaremorelikelythanmentosmokeinanattempttocontroltheirweight.a. Trueb. False
14. Ingeneral,itiseasierforawomantostopsmokingthanaman.
a. Trueb. False
15.Womenwhoaresuccessfulatquittingsmokingusuallyhaveoneormorequit
attemptsbeforekickingthehabit.a. Trueb. False
16.Themostcommonconcernwomenhaveaboutstoppingsmokingisthattheywill:a. Becomedepressedb. Drinkmoresociallyc. Loseweightd. Gainweighte. Losefriends
17.TheAHRQClinicalPracticeGuidelinesforSmokingCessationrecommendsthatthe5Asbeusedinsmokingcessationcounseling.The5Asstandfor:
a. Advise,Attitude,Attention,Adaptability,Arrangeb. Ask,Advise,Assess,Assist,Arrangec. Adversity,Adaptability,Attitude,Ask,Assistd. Ask,Allocate,Assess,Assist,Arrangee. Ask,Advise,Assess,Assist,Adhere
18.BasedonMrs.Montoyasweightandheight,herBMIscorefallsintothefollowingcategory:
a. Normalweight
b. Mildlyoverweightc. Moderatelyoverweightd. Severelyoverweighte. Underweight
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19.WhatadvicewouldyougivetoMrs.Montoyaaboutherweightstatus?
a. Gain5poundsb.
Maintaincurrentweightc. Lose5poundsd. Lose10%ofcurrentweighte. Noneoftheabove
20.Ofthefollowing,whatwouldyourecommendinorderforMrs.Montoyatostart
losingweight?a. Lowerthenumberofcaloriesinherdietbyreducingfatb. Moderatelevelsofphysicalactivityfor3045minutes,3-5daysperweekc. Lowerthenumberofcaloriesinherdietbyreducingsaturatedfatand
carbohydratesd. A&Be. B&C
21.WhatmightyoualsorecommendtoMrs.Montoyaforherweightlossplan?
a. Recordtheamountandtypeoffoodeatendaily(keepalog)b. Keeparecordofthefrequencyofexercisec. Purchaseapedometerandwearitdaily.Recordthenumberofdailystepsd. Enlistthesupportoffamilymembersand/orfriendse. Alloftheabove
22.Theprevalenceofobesityisgreatestinwhatgroup(accordingtoNHANESIII)?
a. Non-HispanicBlackwomenb. Mexican-Americanwomenc. White,non-Hispanicwomend. Non-HispanicBlackmene. Mexican-Americanmen
23.Obeseindividualsaremorelikelythanleanindividualstohavewhichofthe
following?a. LowLDLcholesterolb. LowHDLcholesterolc. Hightriglyceridesd. Type1diabetesmellitus
e. B&C
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24.Anappropriatecomprehensiveresourcetoreferenceforclinicalinformationand
guidelinesonobesityis:a. ATPIIIb. JNC7c.
ClinicalGuidelinesontheIdentification,Evaluation,andTreatmentofOverweightandObesityinAdults(NIHPublicationNo.98-4083)d. MerckManuale. Alloftheabove
25. IntakingthefamilyhistoryonMrs.Montoya,shetellsyouthatyeshermother
hasheartdisease,shehadsurgeryononeofherheartvalves.HowdoeshermothersvalvularheartdiseaseimpactMrs.MontoyasownriskforCAD?
a. Increasesriskby1%peryearb. Increasesriskby3%peryearc. Increasesriskgloballyd. Doesnotimpactriskatalle. Noneoftheabove
26. IntheUnitedStates,nearlytwiceasmanywomen(12.0percent)asmen(6.6
percent)areaffectedbyadepressivedisordereachyear.a. Trueb. False
27.TheFraminghamriskscoreestimatestheriskofdevelopingCHDwithina:
a. 5-yeartimeperiodb. 10-yeartimeperiodc. 15-yeartimeperiodd. 20-yeartimeperiode. lifetime
28.TheFraminghamRiskscoreiscalculatedbasedonthefollowing:a. Ageandsmokingstatusb. Presence/absenceofdiabetesc. Bloodpressureresultsd. HDL/LDLvaluese. Alloftheabove
29.BasedonMrs.Montoyasmedicalhistoryandriskfactorprofile,herFramingham
riskscoreis:a. >10%b. 5%c. 4%d. 2%e. 1%
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ExaminationQuestions(MultipleChoice)
CVDPresentation/MedicalWork-up/DifferentialDiagnosis/TreatmentAdvanced Learner
1. Adifferentialdiagnosisoffatigueinwomencaninclude:a. Hypothyroidismb. Anemiac. Deconditioningd. Heartdiseasee. Alloftheabove
2. Adifferentialdiagnosisofshortnessofbreathinapostmenopausalwomancan
include:a. Congestiveheartfailureb. Heartdiseasec. Anemiad. COPDe. Alloftheabove
3. Estrogentherapywithoutprogesteroneisanappropriatetreatmentoptionto
relievemenopausalsymptomsinanotherwisehealthywomanwhohashadahysterectomy.
a. Trueb. False
4. Menopausalhormonetherapywithestrogenandprogesteronemayincreasethe
riskofwhichofthefollowing?a. Coronaryarterydiseaseb. Pulmonaryembolismc. Breastcancerd. Strokee. Alloftheabove
5. Mrs.Montoyaistakingcaptopril25mgt.i.d.andHCTZ25mgdailyforblood
pressuremanagement.Onexam,herbloodpressurereads144/90.Whatisyourevaluationandrecommendationfortherapy?
a. Bloodpressurecontrolachieved,continuecurrentmedicationplan
b. InstructMrs.Montoyatoloseweight,continuethesamemedications,andfollow-upin3months
c. Titratemedicationsforfurtherbloodpressurereduction,follow-upin1month
d. Considerswitchingmedicationsalltogether,todayonthisvisite. Noneoftheabove
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6. AllofthefollowingareallsecondarycausesofhypercholesteremiaEXCEPT:a. Pregnancyb.
Hypothyroidismc. Nephroticsyndromed. Corticosteroidtreatmente. Gout
7. WhichofthefollowingisNOTafactorusedforthediagnosisofmetabolic
syndrome?a. Waistcircumferenceb. Triglycerideslevelc. Fastingglucosed. Bloodpressuree. Bodymassindex
8. AccordingtoATPIII,pharmacotherapyforwomenwithmetabolicsyndrome
shouldincludeanti-hypertensivemedicationstolowerbloodpressureandtreatmentoftheprothromboticstatewithaspirin.
a. Trueb. False
9. First-linetherapiesinthemanagementofthemetabolicsyndromeinclude:a. Weightreductionandphysicalactivityb. TheDASHeatingplanandweightmaintenancec. PhysicalactivityandtheDASHeatingpland. SmokingcessationandtheDASHeatingplan
10. Mrs.MontoyasECGfindingsondobutaminestresstesting(STelevationin
V4-V6,IIandAVFatpeakheartrate)indicateprobabledecreasedbloodflowinwhatcoronaryarteries?
a. Leftanteriordescendingcoronaryarteryb. Rightcoronaryarteryc. Leftmaincoronaryarteryd. Alloftheabove
11. Contraindicationstodobutaminestresstestinginclude:
a. Severeaorticstenosisb. Unstableanginac. Asthmad. Acutemyocardialinfarction(within2days)e.A,B,&D
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12.Dailyaspirintherapyforthepreventionofheartdiseaseshouldberecommended
towhichofthefollowingwomen?a. High-riskwomenunlesscontraindicatedb. Intermediateriskwomenaslongasbloodpressureiscontrolledc.
Lowriskwomenyoungerthan45yearsofaged. A&Be. B&C
13. Angiotensinconvertingenzymeinhibitorsareagoodchoiceoftherapyforwhat
typeofhypertensivepatient?a. Adiabeticwomanb. Awomanwithrenalinsufficiencyc. Apregnantwomand. Noneoftheabovee. A&B
14. WhichofthefollowingdrugsdoestheJNCVIIrecommendformostpatients
withuncomplicatedhypertension,eitheraloneorincombinationwithotherdrugs?
a. Thiazidediureticb. Angiotensinconvertingenzymeinhibitorc. Betablockerd. Calciumchannelblockere. Angiostensinreceptorblocker
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AnswerKey
EXAMINATIONQUESTIONS(MultipleChoice)RiskFactorIdentification/Management
Early Learner1. AllofthefollowingareknownmajorriskfactorsforCVDexceptfor:
a. Small vessel cerebrovascular diseaseb. Diabetesc. Smokingd. Obesitye. Hypertension
2. Whichriskfactorelevatesawomansriskforheartdiseasebyapproximately3-6
fold?a. BMI>25b. Sedentarylifestylec. Hyperlipidemiad. Smokinge. Age>55
3. Whichwomanhasthegreatestriskforheartdiseasebasedonethnicityalone?
a. NativePacificIslanderb. AsianAmericanc. African Americand. Latinae. Caucasian
4. Currentcomprehensiveguidelinesformanagementofhypertensioncanbefoundinthefollowingreport:
a. JNC 7b. ATPIIIc. MerckManuald. SurgeonGeneralsAnnualReporte. Alloftheabove
5. Allofthefollowingaremajorlifestylemodificationsshowntolowerblood
pressureEXCEPTfor:
a. Quittingsmokingb. Eliminatingcaffeinec. Quittingworkd. Takingyogaclassese. None of the above
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6. TheDASHeatingplanisrichinthefollowing:
a. Magnesium&potassiumb. Calciumc. Protein&fiberd.
OnlyA&Be. All of the above
7. Whichclinicaldisease/condition,accordingtoATPIII,confershighriskforcoronaryheartdisease(CHDRiskEquivalent)?
a. Asthmab. Hypertensionc. Abdominal aortic aneurysmd. Hyperlipidemiae. Depression
8. Whichclinicaldisease/condition,accordingtoATPIII,confershighriskfor
coronaryheartdisease(CHDRiskEquivalent)?a. FamilyHistoryb. Diabetesc. Smokingd. Elevatedhs-CRPe. Morbidobesity
9. BasedonMrs.Montoyaslipidresultsandriskfactorprofile,theATPIII
recommendedapproachtoherdyslipidemiawouldinclude:a. AfibratedrugtoraiseherHDLcholesterolb. Avoidance of high carbohydrate diets to lower her triglyceridesc. IncreasedalcoholintaketoraiseherHDLcholesterold. Alloftheabovee. Noneoftheabove
10. IfapatienttakingastatinmedicationweretoreduceherLDLcholesterolby20%,
heroverallriskofacardiaceventwoulddecreaseby:a. 10% b. 15%c. 20%d. 25%e. 30%
11.Theprimarytargetforcholesterol-loweringtherapyis:
a. HDLb. Triglyceridesc. LDLd. Totalcholesterole. A&C
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12.Thepresenceofdiabetes:
a. ShouldmodifytreatmentgoalsforLDLcholesterolb. Shouldbetreatedasaseparatecategoryofhigherriskc. ElevatesriskforCVDsubstantiallyd.
Noneoftheabovee. All of the above
13.Womenaremorelikelythanmentosmokeinanattempttocontroltheirweight.a. Trueb. False
14. Ingeneral,itiseasierforawomantostopsmokingthanaman.
a. Trueb. False
15.Womenwhoaresuccessfulatquittingsmokingusuallyhaveoneormorequit
attemptsbeforekickingthehabit.a. Trueb. False
16.Themostcommonconcernwomenhaveaboutstoppingsmokingisthattheywill:a. Becomedepressedb. Drinkmoresociallyc. Loseweightd. Gain weighte. Losefriends
17.TheAHRQClinicalPracticeGuidelinesforSmokingCessationrecommendsthatthe5Asbeusedinsmokingcessationcounseling.The5Asstandfor:
a. Advise,Attitude,Attention,Adaptability,Arrangeb. Ask, Advise, Assess, Assist, Arrangec. Adversity,Adaptability,Attitude,Ask,Assistd. Ask,Allocate,Assess,Assist,Arrangee. Ask,Advise,Assess,Assist,Adhere
18.BasedonMrs.Montoyasweightandheight,herBMIscorefallsintothefollowingcategory:
a. Normalweight
b. Mildlyoverweightc. Moderately overweightd. Severelyoverweighte. Underweight
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19.WhatadvicewouldyougivetoMrs.Montoyaaboutherweightstatus?
a. Gain5poundsb.
Maintaincurrentweightc. Lose5poundsd. Lose 10% of current weighte. Noneoftheabove
20.Ofthefollowing,whatwouldyourecommendinorderforMrs.Montoyatostart
losingweight?a. Lowerthenumberofcaloriesinherdietbyreducingfatb. Moderatelevelsofphysicalactivityfor3045minutes,3-5daysperweekc. Lowerthenumberofcaloriesinherdietbyreducingsaturatedfat&
carbohydratesd. A&Be. B & C
21.WhatmightyoualsorecommendtoMrs.Montoyaforherweightlossplan?
a. Recordtheamountandtypeoffoodeatendaily(keepalog)b. Keeparecordofthefrequencyofexercisec. Purchaseapedometerandwearitdaily.Recordthenumberofdailystepsd. Enlistthesupportoffamilymembersand/orfriendse. All of the above
22.Theprevalenceofobesityisgreatestinwhatgroup(accordingtoNHANESIII)?
a. Non-Hispanic Black womenb. Mexican-Americanwomenc. White,non-Hispanicwomend. Non-HispanicBlackmene. Mexican-Americanmen
23.Obeseindividualsaremorelikelythanleanindividualstohavewhichofthe
following?a. LowLDLcholesterolb. LowHDLcholesterolc. Hightriglyceridesd. Type1diabetesmellitus
e. B &C
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24.Anappropriatecomprehensiveresourcetoreferenceforclinicalinformationand
guidelinesonobesityis:a. ATPIIIb. JNC7c. Clinical Guidelines on the Identification, Evaluation, and Treatment ofOverweight and Obesity in Adults (NIH Publication No. 98-4083)d. MerckManuale. Alloftheabove
25. IntakingthefamilyhistoryonMrs.Montoya,shetellsyouthatyeshermother
hasheartdisease,shehadsurgeryononeofherheartvalves.HowdoeshermothersvalvularheartdiseaseimpactMrs.MontoyasownriskforCAD?
a. Increasesriskby1%peryearb. Increasesriskby3%peryearc. Increasesriskgloballyd. Does not impact risk at alle. Noneoftheabove
26. IntheU.S.,nearlytwiceasmanywomen(12.0percent)asmen(6.6percent)are
affectedbyadepressivedisordereachyear.a. Trueb. False
27.TheFraminghamriskscoreestimatestheriskofdevelopingCHDwithina:
a. 5-yeartimeperiodb. 10-year time periodc. 15-yeartimeperiodd. 20-yeartimeperiode. lifetime
28.TheFraminghamRiskscoreiscalculatedbasedonthefollowing:a. Ageandsmokingstatusb. Presence/absenceofdiabetesc. Bloodpressureresultsd. HDL/LDLvaluese. All of the above
29.BasedonMrs.Montoyasmedicalhistoryandriskfactorprofile,herFramingham
riskscoreis:a. >10%b. 5%c. 4%d. 2%e. 1%
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AnswerKeyExaminationQuestions(MultipleChoice)
CVDPresentation/MedicalWork-up/DifferentialDiagnosis/TreatmentAdvanced Learner
1. Adifferentialdiagnosisoffatigueinwomencaninclude:a. Hypothyroidismb. Anemiac. Deconditioningd. Heartdiseasee. All of the above
2. Adifferentialdiagnosisofshortnessofbreathinapostmenopausalwomancan
include:a. Congestiveheartfailureb. Heartdiseasec. Anemiad. COPDe. All of the above
3. Estrogentherapywithoutprogesteroneisanappropriatetreatmentoptionto
relievemenopausalsymptomsinanotherwisehealthywomanwhohashadahysterectomy.
a. Trueb. False
4. Menopausalhormonetherapywithestrogenandprogesteronemayincreasethe
riskofwhichofthefollowing?a. Coronaryarterydiseaseb. Pulmonaryembolismc. Breastcancerd. Strokee. All of the above
5. Mrs.Montoyaistakingcaptopril25mgt.i.d.andHCTZ25mgdailyforbloodpressuremanagement.Onexam,herbloodpressurereads144/90.Whatisyourevaluationandrecommendationfortherapy?
a. Bloodpressurecontrolachieved,continuecurrentmedicationplanb. InstructMrs.Montoyatoloseweight,continuethesamemedications,and
follow-upin3monthsc. Titrate medications for further blood pressure reduction, follow-up in 1monthd. Considerswitchingmedicationsalltogether,todayonthisvisite. Noneoftheabove
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6. AllofthefollowingareallsecondarycausesofhypercholesteremiaEXCEPT:a. Pregnancyb.
Hypothyroidismc. Nephroticsyndromed. Corticosteroidtreatmente. Gout
7. WhichofthefollowingisNOTafactorusedforthediagnosisofmetabolicsyndrome?
a. Waistcircumferenceb. Triglycerideslevelc. Fastingglucosed. Bloodpressuree. Body mass index
8. AccordingtoATPIII,pharmacotherapyforwomenwithmetabolicsyndrome
shouldincludeanti-hypertensivemedicationstolowerbloodpressureandtreatmentoftheprothromboticstatewithaspirin.
a. Trueb. False
9. First-linetherapiesinthemanagementofthemetabolicsyndromeinclude:a. Weight reduction and physical activityb. TheDASHeatingplanandweightmaintenancec. PhysicalactivityandtheDASHeatingpland. SmokingcessationandtheDASHeatingplan
10. Mrs.MontoyasECGfindingsondobutaminestresstesting(STelevationin
V4-V6,IIandAVFatpeakheartrate)indicateprobabledecreasedbloodflowinwhatcoronaryarteries?
a. Leftanteriordescendingcoronaryarteryb. Right coronary arteryc. Leftmaincoronaryarteryd. Alloftheabove
11. Contraindicationstodobutaminestresstestinginclude:
a. Severeaorticstenosisb. Unstableanginac. Asthmad. Acutemyocardialinfarction(within2days)e. A, B, & D
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12.Dailyaspirintherapyforthepreventionofheartdiseaseshouldberecommended
towhichofthefollowingwomen?a. High-riskwomenunlesscontraindicatedb. Intermediateriskwomenaslongasbloodpressureiscontrolledc.
Lowriskwomenyoungerthan45yearsofaged. A & Be. B&C
13. Angiotensinconvertingenzymeinhibitorsareagoodchoiceoftherapyforwhat
typeofhypertensivepatient?a. Adiabeticwomanb. Awomanwithrenalinsufficiencyc. Apregnantwomand. Noneoftheabovee. A & B
14. WhichofthefollowingdrugsdoestheJNCVIIrecommendformostpatients
withuncomplicatedhypertension,eitheraloneorincombinationwithotherdrugs?
a. Thiazide diureticb. Angiotensinconvertingenzymeinhibitorc. Betablockerd. Calciumchannelblockere. Angiostensinreceptorblocker
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The Heart Truth Professional Educational CampaignThe Case of Mrs. Montoya
Reference ListBehaviorChange
EvaluatingPrimaryCareBehavioralCounselingInterventions:AnEvidence-basedApproach.AmJPrevMed2002;22:267-84.http://www.ahrq.gov/clinic/3rduspstf/behavior/behsum1.htm
TheoryataGlance:AGuideforHealthPromotionPractice,NIHPublicationNo.95-3896.http://cancer.gov/cancerinformation/theory-at-a-glance
ZimmermanG,OlsenC,BosworthM.AStagesofChangeApproachtoHelpingPatientsChangeBehavior.AmericanFamilyPhysician,2000;61:1409-1416.http://www.aafp.org/afp/20000301/1409.html
SelectedEvidenceforBehaviorApproachestoChronicDiseaseManagementinClinicalSettings:CardiovascularDisease.http://www.cfah.org/publications.cfm
Consumer Tools
GuidetoBehaviorChange:YourWeightIsAsImportantToUsAsItIsToYou!http://www.nhlbi.nih.gov/health/public/heart/obesity/lose wt/behavior.htm
TheHeartTruthCampaignConsumerWebsitehttp://www.hearttruth.gov
TheHeartHealthyHandbookforWomen,NIHPublicationNo.05-2720http://www.nhlbi.nih.govNHLBIDiseasesandConditionsIndexhttp://www.nhlbi.nih.gov/health/dci
Communication
Stuart,MR;LiebermanJR.BATHE:AusefulMnemonicforElicitingthePsychosocialContext.TheFifteen-MinuteHour:AppliedPsychotherapyforthePrimaryCarePhysician,2ndEd.NewYork:Praeger,2003.
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http://www.ahrq.gov/clinic/3rduspstf/behavior/behsum1.htmhttp://www.ahrq.gov/clinic/3rduspstf/behavior/behsum1.htmhttp://cancer.gov/cancerinformation/theory-at-a-glancehttp://cancer.gov/cancerinformation/theory-at-a-glancehttp://www.aafp.org/afp/20000301/1409.htmlhttp://www.aafp.org/afp/20000301/1409.htmlhttp://www.cfah.org/publications.cfmhttp://www.cfah.org/publications.cfmhttp://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/behavior.htmhttp://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/behavior.htmhttp://www.hearttruth.gov/http://www.nhlbi.nih.gov/http://www.nhlbi.nih.gov/http://www.nhlbi.nih.gov/health/dcihttp://www.nhlbi.nih.gov/health/dcihttp://www.nhlbi.nih.gov/health/dcihttp://www.nhlbi.nih.gov/http://www.hearttruth.gov/http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/behavior.htmhttp://www.cfah.org/publications.cfmhttp://www.aafp.org/afp/20000301/1409.htmlhttp://cancer.gov/cancerinformation/theory-at-a-glancehttp://www.ahrq.gov/clinic/3rduspstf/behavior/behsum1.htm7/27/2019 Cases Nurses
68/72
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CulturalDiversity
Like,RobertC.TRANSLATE:AMnemonicforWorkingwithMedicalInterpreters.1997.MSCenterforHealthyFamiliesandCulturalDiversityDepartmentofFamilyMedicineUMDNJ-RobertWoodJohnsonMedicalSchool.http://www.state.nj.us/health/fhs/bibs/education/translate.html
Levin,SJ;Like,RC;Gottlieb,JE.ETHNIC:AFrameworkforCulturallyCompetentClinicalPractice.PatientCare2000;34:188-189.
Depression
SherrillJT,AndersonB,FrankE,etal.Islifestressmorelikelytoprovokedepressiveepisodesinwomenthaninmen?DepressionandAnxiety,1997;6:95-105.
Depression:WhatEveryWomanShouldKnow.NationalInstituteofMentalHealth2005.
http://www.nimh.nih.gov/health/publications/depression-what-every-woman-should-know/summary.shtml
DiagnosticTesting
MieresJH,ShawLJ,AraiA,etal.Roleofnoninvasivetestingintheclinicalevaluationofwomenwithsuspectedcoronaryarterydisease:consensusstatementfromtheCardiacImagingCommittee,CouncilonClinicalCardiology,andtheCardiovascularImagingandInterventionCommittee,CouncilonCardiovascularRadiologyandIntervention,
AmericanHeartAssociation.Circulation.2005;8;111:682-96.http://circ.ahajournals.org/cgi/content/full/111/5/682
GibbonsRJ,BaladyGJ,BrickerJT,etal.ACC/AHA2002guidelinesupdateforexercisetesting:areportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines(CommitteetoUpdatethe1997ExerciseTestingGuidelines).JAmCollCardiol2002;40:1531-1540.http://www.acc.org/qualityandscience/clinical/guidelines/exercise/dirindex summary.htm
CheitlinMD,ArmstrongWF,AurigemmaGP,etal.ACC/AHA/ASE2003guidelineupdatefortheclinicalapplicationofechocardiography:areportoftheAmericanCollege
ofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines(ACC/AHA/ASECommitteetoUpdatethe1997GuidelinesfortheClinicalApplicationofEchocardiography).JAmSocEchocardiogr2003;16:1091-1110.http://circ.ahajournals.org/cgi/content/full/108/9/1146
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http://www.state.nj.us/healthRecommended