When she stops walking, and rests, the pain completely resolves. When asked to point to where her pain is she points to the are above her left breast. She states it radiated to her left shoulder, and occasionally gets “a strange tingling” in her left arm. She denies any fever, chills, nausea, vomiting or diarrhea. Denies cough, occasional shortness of breath; but not new for her. She denies headaches or feeling like she is dizzy, or going to pass out. She denies any history or Family history of PE or DVT. She used to smoke 1PPD of cigarettes for 30 years, but quit at age 65. She denies any arm or leg swelling.
PMHX: HTN, HLD, CAD, DM, COPD, Hypothyroid
Medications: Lisinopril 10mg Once daily, Amlodipine 5mg Daily, Lipitor 40mg once daily, Pepcid 40mg BID, Ventolin Inh. PRN Q6hours, Metformin 1000mg BID, Synthroid 125mcg daily
Surgical HX: CABGX2 (2016)
FHX: Mother(87yo) COPD, HTN, CAD Deceased, Father (89yo) Deceased d/t MI, Husband (69yo) HTN, Asthma, COPD, Daughter (34yo) Healthy, Son (38yo) Schizophrenia, Daughter (35yo) HIV
Social HX: Smokes 1PPD of cigarettes; Quit 30 years ago, ETOH use (6-7 vodka seltzers/week)
VS: Temp 98.8 oral, HR 98, BP 168/76, RR 20, SPO2 90% RA HT:5’7”, WT: 185lbs
Physical Exam: This is a 76yo African American female, appears states age. 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 BL posterior lung 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. No focal neurological deficit.
Diagnostic Studies: EKG Normal Sinus with PVC
CBC: Hgb 12.5, Plts 250,
CMP: BUN 30, CREA 1.0, Na 137, K 3.6, Glucose 118, BNP 90
Chest X-Ray: No infiltrates, Heart size normal, No Rib Fractures
Please follow same rubric for Case Study 1. Do not submit a case study that does not have a full ROS and PE, it will not be graded.
Instructions: Reformat the above data as follows from Bates:
Your 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)
ROS – complete information
Physical Exam – complete information
2). List 3 Differential Diagnoses in descending order of suspicion (your 1st differential should be your primary).
3). List the pertinent positives/negatives to support your differentials. (3positive/3negative)
4). List additional history data that would support your primary differential diagnosis and why? (5 history questions not already asked you would ask patient to obtain more data)
5). List any additional physical components that would support your primary differential diagnosis and why? (3-5 PE findings that are not provided that would help you diagnose)
6). Select your primary differential diagnosis as #1 and include 2 other differentials:
- Give a brief pathophysiologic description of each disorder (< 10 sentences) of your #1 differential.
- Etiology (of your #1 differentials
- Usual clinical findings or features, if any, associated with your primary DD
- Diagnostic criteria (if any) for making the diagnosis
- Treatment Plan – include specific treatments like pharmacotherapy (be specific with doses, amounts, etc)
Remember to use 1 evidence-based source within last 5 years for case study.
Cite in APA format
Put name on case study before submitting
Expert Answer Explanation
NUR631L Case Study 1
Patient: Shirley
Time: 07/04/2024
Source and Reliability: Self-referred, reliable
CC: “I have been having chest pain for the last four days.”
HPI: Summary of what patient came to see you for based on scenario provided
Shirley is a 76yo female who presented to the clinic with complains of chest pain that has lasted about four days. She noted that she has been experiencing chest pain occasionally. However, four days ago, she noticed that the pain increased when she was engaged in activities such as her morning walk or walking the stairs and decreased when she rested. The chest pain radiates to her left shoulder and breasts. She also noted that he experiences tingling in her left arm.
PMH:
- Childhood illnesses/conditions: No childhood illness.
- Medical Conditions: HTN, HLD, CAD, DM, COPD, Hypothyroid
- Surgical Hx: CABGX2 (2016)
Current medications:
- Lisinopril 10mg Once daily
- Amlodipine 5mg Daily
- Lipitor 40mg once daily,
- Pepcid 40mg BID
- Ventolin Inh. PRN Q6hours
- Metformin 1000mg BID
- Synthroid 125mcg daily
Allergies: No allergies
Psychosocial: She is married to her husband of 69 yo. She has three children, two daughters, one is 35 years old and the other is 34 years old and a son aged 38yo. She used to smoke1PPD of cigarettes. However, she quit 30 years ago. She takes 6-7 vodka seltzers/week. She often goes for a morning walk to take coffee with her girlfriends.
Family History – genogram
ROS
- General: She denies chills, fever, nausea, or fatigue.
- Skin: She denies rashes or itching
- Head, Eyes, Ears, Nose, Throat (HEENT): Head: She denies lightheadedness, headache, or dizziness. Eyes: She denies use of glasses, vision problems, or pain in the eyes. No double vision. Ears: She denies earaches, discharge, infections, vertigo, or hearing problems. Nose and sinuses: She deny nasal stuffiness, frequent colds, hay fever, discharge, or sinus trouble. Throat (or mouth and pharynx): She denies bleeding gums, hoarseness, sore tongue, sore throats, or dry mouth.
- Neck: She denies stiffness or pain in the neck or swollen glands.
- Breasts: She denies nipple discharge.
- Respiratory: She denies cough, shortness of breath, pleuritic pain, or wheezing.
- Cardiovascular: Reports chest pain for four days. She denies edema.
- Gastrointestinal: Denies nausea, diarrhea, heartburn, or trouble swallowing. No abdominal pain.
- Peripheral Vascular: Denies varicose veins, leg cramps, or swelling in calves.
- Urinary: She denies nighttime urination, UTIs, hematuria, or flank or kidney pain.
- Genital: She denies menstruation.
- Musculoskeletal: Denies muscle or joint pain or stiffness. Denies history of trauma.
- Psychiatric: No depression, suicidal plans, or changes in mood.
- Neurologic: She denies speech problem or memory problems. She reports tingling of the left arm.
- Hematologic: She denies bleeding.
- Endocrine: She denies endocrine problems.
Physical Exam – complete information