Cases Nurses

7/27/2019 Cases Nurses

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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

I-3


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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

FG-2


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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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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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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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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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Chief/primarycomplaint FatigueSpanishconnotationversusEnglishconnotation;understandingwhat

thepatientmeansbyusingthewordfatigue;causesoffatigue Additionalbarrierstoseekinghealthcare

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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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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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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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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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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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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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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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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.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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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.

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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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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.htm


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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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