NUR 631 LAB: Case Study – Mr. J, 56-year-old male complains of chest pain

NUR 631 LAB: Case Study – Mr. J is a 56-year-old male complains of chest pain

Case Study 2 Fall 2022

History: Mr. J is a 56-year-old male, who presented to your office today for complaints of chest pain. He states that his pain has been occurring intermittently for 3 days. He admits that with any strenuous activity he develops this pain in his chest. When he points to the area where he is describing, it is by his left areola. He states he has been fatigued, and very “winded” with any exertion. He denies any recent travel and denies any sick contacts at home. (Chest Pain Case Study)

He has been vaccinated for COVID with 3 vaccines. He denies any history of PE/DVT. Denies any extremity swelling or pain. He denies cough. He has had poor appetite over the past 3 days. Denies nausea, vomiting or diarrhea. He admits that last evening while sitting on his couch, he has “pins and needles” in his left arm, which went all the way to his fingertips. He smokes 1 pack of cigarettes a day. Has a “chronic cough” he states.

PMHX: HTN, HLD, CAD, DM, COPD (not on home oxygen), GERD

Medications: Lisinopril 10mg Once daily, Norvasc 5mg Daily, Lipitor 40mg once daily, Pepcid 20mg BID, Ventolin Inh. PRN Q6hours, Metformin 500mg BID

Surgical HX: CABGX2 (2020)

FHX: Mother(87yo) COPD, HTN, CAD, Father (89yo) Deceased d/t MI, Wife (50yo) HTN, COPD, Daughter (30yo) Healthy, Son (32yo) Schizophrenia, Daughter (34yo) HIV

Social HX: Smokes 1PPD of cigarettes, occasional cocaine use, ETOH use (6-9 beers/week)

VS: Temp 97.7 oral, HR 86, BP 155/65, RR 16, SPO2 97% RA HT:5’7”, WT: 260lbs

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56-year-old male complains of chest pain
56-year-old male complains of chest pain

Physical Exam: This is a 56yo Caucasian male, appears states age. Tobacco-stained fingernails. A&OX3, Well dressed. Oral mucosa pink, moist, intact. Poor dentition with multiple areas of plaque/dental caries. EOMI, PERRLA 2+ BL, Neck supple, no palpable thyroid. No JVD or cervical lymphadenopathy. Chest wall without pain to palpation, no rashes/lesions noted. Lungs with scattered wheezes/rhonchi that clear with coughing. No egophony, bronchophony, or whispered pectoriloquy. Heart with normal s1/s2, no murmur appreciated to auscultation. 2+ pulses in BL upper and lower extremities. Calves are symmetric, temperature intact BL, with negative homan’s sign BL. 1+ edema in BL lower extremities. ROM intact in all joints. ABD is SNTTP, BS X 4.

Diagnostic Studies: EKG Normal Sinus Rhythm, Hgb 10.5, Plts 250, BUN 25, CREA 0.9, Na 135, K 3.7, Glucose 140, BNP 98

Instructions: Reformat the above data as follows from Bates:

You must include a full ROS and Physical Exam for full Credit

1). CC:

HPI

PMH (include surgeries and traumatic injuries)

Current medications

Allergies

Psychosocial

Family History – genogram (you can draw it and place on last page, or create in word document)

ROS – complete information

Physical Exam – complete information

2). List 3 Differential Diagnoses in descending order of suspicion

(Number these as #1, #2, #3, your #1 should be your primary working DX)

3). List the pertinent positives/negatives to support your differentials. (at least 3 of each)

4). List additional history data that would support your primary differential diagnosis and why? (At least 10 history questions listed)

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5). List any additional physical components that would support your primary differential diagnosis and why? (At least 5 PE findings that would better help you diagnose your primary differential)

6). Select your primary differential diagnosis as #1 and include 2 other differentials:

a) Give a brief pathophysiologic description of each disorder (< 10 sentences)

b) Etiology (primary dx)

c) Usual clinical findings or features (primary dx)

d) Diagnostic criteria (if any) for making the diagnosis (primary dx)

e) Treatment Plan – include specific treatments like pharmacotherapy (be specific with doses, amounts, etc.) (for your PRIMARY DX)

Solution:Chest Pain Case Study

CASE 1

Patient Information: A 36-year-old female

S.

CC: “Constantly feeling tired even after a period of rest.”

HPI: The patient present complains of persistent tiredness even after rest. The patient reports that she lacks energy every day after a day’s job, which began a few months ago but has progressively gotten worse. She reports missing several workdays due to a lack of energy even after showering and dressing for work. She reports sleeping more than eight hours a night while needing several naps throughout the day.  She reports an uncomfortable buzzing sensation traveling from the neck down to the spine with what sounds to be a Lhermitte’s sign. Uses interferon to manage MS, CBD oil to help with energy without relief, and Cetirizine 10 mg PO daily to manage allergies(Chest Pain Case Study)

Current Medications:

Interferon to manage MS

CBD oil to help with energy without relief

Cetirizine 10 mg PO daily to manage allergies

Allergies: Nasal congestion.

PMx: Diagnosed with Multiple Sclerosis 3 years ago. Up to date with her pap smear. She goes for a monthly self-breast exam.  Saw her dentist and eye doctor within the last year.

Soc Hx: Has a full-time job. Occasionally drinks wine during the weekend. Denies tobacco or illicit drug use.  

Fam Hx: Married with two children. Her other has diabetes and has hypertension. Farther and siblings are alive and well. She has an aunt diagnosed with MS and is wheelchair-bound. 

ROS:

GENERAL: Denies fever, chills, weight loss, or gain.

HEENT: Face symmetrical.  PERRLA is normal. No retinal hemorrhages or exudates. Reports nasal congestion. Oral mucosa pink and moist

SKIN: Dry, warm, and intact

CARDIOVASCULAR:  Heart rate bradycardic. No chest pain, chest pressure, or chest discomfort

RESPIRATORY:  Regular breath. No pauses or extra beats.  

NEUROLOGICAL:  Reports nasal congestion. She denies loss of bowel or bladder. 

MUSCULOSKELETAL: Normal muscle function. Muscle tone palpated. No fasciculation, tenderness or atrophy.  Buzzing sensation in the neck down the spine.

HEMATOLOGIC: Conjunctivae rim pale.

LYMPHATICS:  No lymphadenopathy.

PSYCHIATRIC:  No depression or anxiety. No history of splenectomy.

ENDOCRINOLOGIC:  No thyromegaly.

ALLERGIES: Nasal congestion.  

CASE 2

Patient Information: A 35-year-old male

S.

CC: “Acute low back pain.”

HPI: The patient experienced an acute onset of low back pain radiating down the back of the left leg following yard work. The pain has worsened in intensity, and he is having difficulty bearing weight on the leg. The pain ease with Ibuprofen 800mg. Rates pain eight out of 10, described as sharp, lightening sensation. (Chest Pain Case Study)

Current Medications:

Ibuprofen 800 mg to manage the pain.

PMx: Denies hospitalizations or surgical history. He sees primary care provider when he has an acute issue. 

Soc Hx: Works for IT department from home. Sits about 8 hours per day.  Reports smoking a pack of cigarettes a day ten years but quit five years ago. Currently vapes daily.  He reports one beer with dinner. Denies illicit drug use.

Fam Hx: He recently divorced and shared custody of three children. Denies family history of the spine or musculoskeletal diseases or malignancy.

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Health promotion: No regular health maintenance. Runs for at least 30 minutes daily. Eats healthy.

ROS:

GENERAL: Denies fever, chills, weight loss, or weight gain.

HEENT:  Eyes:  No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose, or sore throat.(Chest Pain Case Study)

SKIN: No rashes or bruising.

CARDIOVASCULAR:  No chest pain, chest pressure, or chest discomfort.

RESPIRATORY:  No shortness of breath, cough, or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting, or diarrhea.

NEUROLOGICAL:  Denies headaches, dizziness. Severe pain with active movement. Minimal pain with passive motion. Denies loss of bowel or bladder or saddle anesthesia.

MUSCULOSKELETAL: Denies history of lower back pain or previous back injury. 

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy

PSYCHIATRIC:  No depression or anxiety

ENDOCRINOLOGIC:  ENDOCRINOLOGIC:  No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No NKFDA

CASE 3

Patient Information: An 83-year-old female

S.

CC: “A productive cough.”

HPI: The patient presentsa productive cough for the last three weeks. She reports fever on and off. She has chest pain, which worsens at night. She has a mild sore throat and nasal congestion.(Chest Pain Case Study)

Current Medications:

Guaifenesin to relieve sore throat and nasal congestion.

Tylenol 500 mg PO daily to manage osteoarthritis.

Citalopram 10 mg PO daily to manage depression

Omeprazole 10 mg PO daily to manage GERD

Levothyroxine 88 mcg PO daily to manage hypothyroidism

Allergies: Allergy to PCN with the reaction of hives.

PMx: No history of asthma or any chronic lung diseases. Diagnosed with osteoarthritis.  Reports depression and GERD. Reports hypothyroidism. Hospitalized for the birth of three children. Had right knee replacement two years ago

Soc Hx: She lives in a retirement community and uses a rolling walker for long-distance walking and a cane around the house. Denies recent travel. She denies smoking, alcohol, or illicit drug use.

Fam Hx: Her children live close by and help her with errands.  All her children are alive and well, no one with similar symptoms.

Health promotion: Up to date on vaccines, including flu and pneumonia vaccine. She wears her mask when she goes out in public and maintains a physical distance of six feet while practicing good hand hygiene. (Chest Pain Case Study)

ROS:

GENERAL: Reports fever.

HEENT:  Eyes:  No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat:  Mucous membranes moist.  No tonsillar exudate, oropharynx clear. Nares patent with clear drainage. Reports sore throat and nasal congestion.

SKIN: No rashes or bruising.

CARDIOVASCULAR:  Reports chest pain and discomfort.

RESPIRATORY:  Reports excessive cough and occasional wheezing. Irregular heartbeats.

GASTROINTESTINAL:  Denies nausea, vomiting, or diarrhea.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy

PSYCHIATRIC:  Reports depression.

ENDOCRINOLOGIC:  No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No asthma.

CASE 4

Patient Information: A 64-year-old

S.

CC: “fatigue.”

HPI: Routine evaluation. The patient complained of fatigue for the past three months. Reports no change in the diet or lifestyle.

Current Medications: Over-the-counter non-steroidal anti-inflammatory medication (NSAID).

Allergies: No history of allergies.

PMx: Denies any past medical history, surgical history, or hospitalizations.

Soc Hx: Retired post office employee. Denies smoking. Reports an occasional beer with friends. Consumes bee three times a day following retirement.(Chest Pain Case Study)

Fam Hx: Reports family history of diabetes, hypertension, cardiac disease, and colon cancer. 

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Health promotion: No regular health maintenance. Runs for at least 30 minutes daily. Eats healthy.

ROS:

GENERAL: Reports fatigue but denies fever or chills. 4-pound weight loss.

HEENT: Reports lightheadedness. Eyes:  Denies changes in visual. Ears, Nose, Throat:   Denies trouble swallowing.

SKIN: No rashes or bruising.

CARDIOVASCULAR:  Denies chest pain. No palpitations. Chest pressure or chest discomfort.

RESPIRATORY:  No shortness of breath, cough, or sputum.

GASTROINTESTINAL:  Denies nausea or vomiting. No abdominal pain.

GENITOURINARY: Denies urinary frequency, burning, or hematuria.

NEUROLOGICAL:  Reports lightheadedness. Normal bowel movements. Dark bowel movement.

MUSCULOSKELETAL: No suprapubic or CVA tenderness.

HEMATOLOGIC: Paleness of conjunctivae and palmar pallor

LYMPHATICS:  No lymphadenopathy or swelling.

PSYCHIATRIC:  No depression or anxiety

ENDOCRINOLOGIC:  Denies cold or heat intolerance. Denies sweating.  

ALLERGIES:  No NKFDA

CASE 5

Patient Information: A 19-year-old female

S.

CC: “headaches frequently.”

HPI:  The patient is a 19-year-old presenting a frequent headache, which has become more debilitating recently. Headache episodes occur at least twice monthly and last for two days. The pain in the right temple or the back of the right eye spreads to the entire scalp for a few hours. The pain is sharp and throbbing. The patient reports severe nausea. Noise and movement aggravate the pain. The pain eases when sleeping in a dark, quiet room.

Current Medications: Naproxen and Acetaminophen to manage the pain.

Allergies: Reports no drug allergies but has seasonal and allergies to pet dander.

PMHx: Persistent headaches.

Soc Hx: Is sexually active uses condoms.  Currently a freshman in college.  Denies alcohol, illicit drug, and tobacco use.

Fam Hx: A thorough history reveals her mother suffers from migraines.

Health Promotion: Last health visit was over the summer, up to date on health maintenance for her age. 

ROS:

GENERAL:  She denies fever, chills, night sweats, or neck stiffness. 

HEENT:  Normocephalic Eyes:  She denies visual changes other than photophobia. Normal visual acuity Ears, Nose, and Throat:Mucous membranes pink and dry.

SKIN:  Warm and dry.

CARDIOVASCULAR:  She denies chest pain, palpitations, or edema.

RESPIRATORY:  Denies shortness of breath or cough.

GASTROINTESTINAL:  She denies abdominal pain but reports some nausea and vomiting.

GENITOURINARY:  Last menses four weeks ago.

NEUROLOGICAL:  Reports headaches.

MUSCULOSKELETAL:  Normal muscle tone.

HEMATOLOGIC:  No anemia, bleeding, or bruising.

LYMPHATICS:  Reports thyroid enlargement. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  Reports adenopathy.

ALLERGIES:  Reports no drug allergies but has seasonal and allergies to pet dander.

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