COMPREHENSIVE CASE STUDY I HUMAN CASE WEEK 7 |49-YEAR-OLD MALE, REASON FOR ENCOUNTER, Exams of Nursing

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COMPREHENSIVE CASE STUDY I HUMAN CASE WEEK 7 |4 9 - YEAR-OLD

MALE, REASON FOR ENCOUNTER: INTERMITTENT SQUEEZING CHEST PAIN

WITH ALL NECESSARY ASPECTS, INCLUDING PHYSICAL EXAM (PE),THE

CHIEF COMPLAINT (CC), DIFFERENTIAL DIAGNOSIS, HISTORY OF PRESENT

ILLNESS (HPI), AND MANAGEMENT PLAN.

Patient Name: Florence Blackman Patient Age: 49 - year-old

Subjective

Chief complaint: Florence Blackman is a 49 - year-old female with a past medical history significant for hypertension and hypercholesterolemia who presents today for complaints of “intermittent squeezing chest pain”. HOPI: The patient is a 49-year-old female who presents to the clinic with complaints of intermittent midsternal chest pain that started two weeks ago. She describes it as a moderate 6/10 “squeezing” pain which radiates to the left arm and is worse with exertion. The patient also reports dyspnea associated with the episodes of chest pain and worsening pain in the cold weather. The pain and shortness of breath has a sudden onset and is only alleviated by rest which sometimes interferes with her ability to do cross-country skiing in the winter. Patient denies any fatigue, fever, chills, nausea, vomiting, sleeplessness, or abdominal discomfort. She denies any allergies or use of over-the-counter prescription medications or herbal supplements to help with symptoms. She reports a past medical history of hypertension for which she is taking 12.5 mg of hydrochlorothiazide daily and hypercholesterolemia which she is attempting to manage with diet changes. The family includes stroke and coronary artery disease. The physical examination is normal, except for a BMI of 25.5. History: Medical:

• Hypertension diagnosed 2 years ago
• Hypercholesterolemia diagnosed 1 year ago, currently uncontrolled Surgical/Hospitalizations:
• No past surgeries, trauma/injuries, or hospitalizations Family Hx:
• Biological father (deceased): stroke at age 65
• Biological mother (deceased): heart disease at age 54
• Biological sister (living): Recent open-heart surgery at age 58 Social Hx Diet:
• Frequently eating fast food and restaurant meals Exercise:
• High-intensity aerobics class three times per week Occupation:

• Marketing executive with own firm that is demanding and requires long work hours Home Environment:
• Patient lives independently in a loft and reports being in a safe environment Tobacco:
• 5 - year history of cigarette smoking, but quit 15 years ago
• Denies use of chewing tobacco or other tobacco products Recreational drugs:
• Denies recreational/illicit drug use Alcohol:
• Reports drinking 1 – 2 glasses of wine a day
• Denies excessive alcohol consumption or history of alcohol abuse Sleep:
• Denies falling or staying asleep Leisure activities/stress reduction:
• Cross-country skiing with friends in the winter to help with work-related stress Allergies: No known allergies Medications: 12.5 mg PO hydrochlorothiazide once daily Vaccines/Immunizations: Up to date on immunizations Preventative Health: Regularly visits primary care provider to monitor cholesterol and blood pressure ROS: Constitutional: Reports being in generally good health overall despite episodes of chest pain and dyspnea for the past two weeks and a reported history of hypertension and hypercholesterolemia. Denies any fever, chills, fatigue/weakness, night sweats, and unintentional weight loss or gain. Reports that her weight has been steady, but understands she is slightly overweight and needs to lose weight. HEENT: Denies runny nose, nasal congestion, or sore throat. Denies recent vision or hearing changes. Denies any difficulties swallowing or jaw/neck pain. Respiratory: Reports worsening dyspnea associated with chest pain, which is alleviated with rest, as well as dyspnea with exertion. Denies history of lung disease or any allergies. Denies nocturnal dyspnea, orthopnea wheezing, difficulty catching breath, or cough/sputum production. Cardiovascular: Reports a history of mild hypertension for which she takes 12.5 mg of hydrochlorothiazide once daily and hypercholesterolemia. She also reports an intermittent squeezing chest pain and dyspnea on exertion typically lasting a few minutes for the past two weeks, especially in the cold weather when she is cross-country skiing. The pain is in the center of her chest, and she rates it as a moderate 6/10. She denies any exercise intolerance and is able to attend a high-intensity aerobics class three times a week despite current symptoms. Denies any palpitation, syncope, or history of irregular heartbeats. Gastrointestinal: Denies nausea, vomiting, constipation, diarrhea, coffee ground emesis, dark tarry stool, bright red blood in bowel movements, early satiety, or bloating. No abdominal pain reported. Musculoskeletal: Reports that the chest pain radiates to left arm. Denies pain, weakness, or swelling in any other extremities or joints. Peripheral vascular: Denies any extremity edema or lower extremity pain.

Objective

Vitals:

Ht: 5’ 6” (168 cm) Wt: 158 lb (71.8 kg) BMI: 25. 5 BP: 132/ HR: 74 RR: 18 T: 98.5 F Physical Exam: General survey: She is alert and oriented to person, place, time, and situation. No signs of acute cardiac/respiratory problems at rest. Hygiene/dress-up is appropriate for situation, able to maintain normal eye contact and facial expressions. BMI 25.5, making her slightly overweight. HEENT: Head is normocephalic, atraumatic, with no deformities. Facial features are symmetric and there is no edema or swelling noted. Conjunctivae are pink with no discharge and there are no signs of cyanosis. No cyanosis is noted around the mouth or lips, and mucous membranes are moist, pink, dry and intact. Pupils are equal, round, reactive to light, and accommodation. Respiratory: Respiratory rate, depth, rhythm, and effort are normal without any audible wheezing, gasping, or grunting. Trachea is midline and there are no signs of trauma to the thorax. No deformities of the thorax anteriorly or posteriorly, retractions, or use of abdominal/accessory muscles noted. There are no areas of tenderness or pain with palpation. Chest expansion is symmetrical, and lung fields are resonant throughout. All lung fields are clear upon auscultation anteriorly and posteriorly, no adventitious sounds are noted. Cardiovascular: Chest is symmetric without any trauma. Regular heart rate, rhythm, and strength. S1 and S heart sounds present. No murmurs, rubs, click, or gallops. PMI is normal and located inside the midclavicular line at the fifth intercostal space. There is no jugular vein distention and patient has normal jugular venous pressure. No abnormal pulsations and/or bruits. Gastrointestinal: Abdomen is nondistended and there are no masses observed. Soft/ non-tender to palpation and tympanic to percussion with dullness over solid viscera. Bowel sounds are present and normoactive in all four quadrants. Patient’s symptoms are not reproduced when applying epigastric pressure. Musculoskeletal: All extremities are symmetric with no deformities present. No localized pain or tenderness. Full range of motion of upper and lower extremities. Strength test is 5/5 bilaterally. Peripheral vascular: No peripheral edema of lower or upper extremities and are warm and dry. Radial pulses are 2+ bilaterally and capillary refill is less than 3 seconds for all extremities. No cyanosis or clubbing in the finger or toenails. Laboratory data :

• Complete blood count (CBC) with differential is normal – no signs of anemia
• Normal creatinine kinase-MB – one of the enzymes that is used to detect myocardial injury along with troponin
• Abnormal serum lipid profile – hypertriglyceridemia and hypercholesterolemia with moderately elevated LDL fraction which can contribute to coronary artery disease
• Normal troponin-T – cardiac myocyte protein released into the blood following myocardial infarction and is most sensitive Imaging data :
• 12 Lead Electrocardiogram – normal sinus rhythm, no ST segment abnormalities

• Abnormal cardiac stress test – ST elevation in the inferior lead suggests inferior ischemia vs. ST depression on exercise testing is of no value
• Transthoracic Echocardiogram – no evidence of structural or functional cardiac abnormalities Normal Chest X-ray

Assessment

Primary Differential Dx: Stable Angina related to coronary artery disease a. Inclusion Criteria: o History of hypercholesterolemia, hypertension, smoking, and overweight status o Family history of cardiac disease o Abnormal serum lipid profile o Normal chest X-ray o Chest pain and shortness of breath with exertion which is relieved with rest b. Exclusion Criteria: o Cardiac stress test showing ST depression in the inferior lead may warrant further testing with an angiography, but patient is refusing Differentials for Primary Problem Alternative DDX: Myocardial Infarction c. Inclusion Criteria: o Chest pain which radiates to the left arm with associated shortness of breath o History of cardiac disease in the family o Patient’s past medical history of hypertension and hypercholesterolemia o Abnormal cardiac stress test d. Exclusion Criteria: o Pain is intermittent and relieved with rest vs. with an MI it would be a constant pain o Troponin levels were normal o Normal ECG and chest X-ray was normal (no evidence of cardiomegaly) o Normal TTE Alternative DDX: Costochondritis a. Inclusion Criteria: o Intermittent chest pain and dyspnea on exertion b. Exclusion Criteria: o Pain and shortness of breath are relieved with rest o No associated costochondral pain or tenderness upon palpation

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