StudyLoop

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.”

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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

  • General: The patient is an average woman, aged 76 yo. She responds too questions well and is well-groomed. She is oriented to place, time, and people. She does not look distressed.
  • Vitals Signs: Temp 98.8 oral, HR 98, BP 168/76, RR 20, SPO2 90% RA HT:5’7”, WT: 185lbs
  • Skin: Fair with no rashes.
  • Head, Eyes, Ears, Nose, Thoat (HEENT): Head: Hair has good texture. NC/AT. Scalp without lesions. Eyes: No glasses. EOMI, PERRLA 2+ BL. Vision 20/20 in each eye. Sclera white, conjunctiva pink. Ears: Hearing is intact. Nose: Sinus not tender, mucosa pink, and septum midline. Mouth: Poor dental health with numerous plaque and dental caries sites. Oral mucosa pink, moist, intact. Tonsils 2+.
  • Neck: Neck supple. No palpable thyroid
  • Thorax and lungs: Thorax has good excursion and symmetric. No wheezes. Lungs with BL posterior lung wheezes/rhonchi that clear with coughing
  • Cardiovascular: S1 and S2 is normal. BP is high. No murmurs. Chest wall without pain to palpation, no rashes/lesions noted.
  • Breasts: No masses. No discharge.
  • Abdomen: Active bowel sounds. Abdomen flat. No masses or tenderness present.
  • Genitalia: No JVD or cervical lymphadenopathy.
  • Rectal: External hemorrhoids not present.
  • Extremities: Edema not present and warm. Nontender.
  • Peripheral vascular: Lower extremities as no varicosities.
  • Musculoskeletal: No swelling or inflammation in the muscles. Range of motion is good.
  • Neurologic: Cooperative and alert. Is oriented. Gait fluid and normal.
  • Sensory: Reflexes: 2+ at triceps, biceps, brachioradialis, achilles tendons, or patellar.

Diagnostic Testing:

  • CMP: BUN 30, CREA 1.0, Na 137, K 3.6, Glucose 118, BNP 90
  • CBC: Hgb 12.5, Plts 250
  • Chest X-Ray: No infiltrates, Heart size normal, No Rib Fractures
  • EKG Normal Sinus with PVC

2). Differential Diagnoses

  • Acute Coronary Syndrome (ACS)
  • Pulmonary Embolism (PE)
  • Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

3). The Pertinent Positives/Negatives to Support the Differentials (3positive/3negative):

Acute Coronary Syndrome (ACS)

Positives

  1. Chest pain for the last four days.
  2. Chest pain spreads to the patient’s left shoulder and in some instances to the left breast.
  3. Symptoms of chest pain start when she exercises or walks up the stairs, but stops at rest.

Negatives

  1. Denies chills, fever, or nausea.
  2. Denies diarrhea or vomiting
  3. Denies shortness of breath.

Pulmonary Embolism (PE)

Positives

  1. Positive for rapid breathing.
  2. Her BNP level is raised.
  3. She has risk factors for PE such as CAD, HTN, and COPD.

Negatives

  1. No coughs or shortness of breath.
  2. The patient’s lungs are normal with no abnormalities
  3. X-ray results show that the chest is normal

Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

Positives

  1. Positive for chest discomfort.
  2. History of COPD.
  3. Positive for rhonchi or wheezes.

Negatives

  1. No shortness of breath.
  2. Negative for fever.
  3. Negative for cough.

4). Additional History Data to Support the Primary Differential Diagnosis

  1. The patient’s family history of heart problems can be used to confirm the diagnosis. Bergmark et al. (2022) noted that individuals whose families have history of heart problems risk developing the disease. Therefore, I would ask the patient if there is any of her immediate family member with heart problems or died of heart disease.
  2. The second question will revolve around the patient’s past medical history. I will ask her if he has ever suffered stroke or heart attacks before (Bergmark et al., 2022). Previous history of heart attacks or stroke increases one’s chances of developing ACS.
  3. I will also ask the patient if she has diabetes. Diabetes is also a risk factor of ACS.
  4. Asking the patient if she was infected with covid-19 virus is also vital because it also increases the patient’s chances of developing ACS (Bergmark et al., 2022).
  5. Lastly, I would assess the patient’s compliance to past treatments. Information about how she complied with her past medication instructions is vital in determining the current diagnosis (Bergmark et al., 2022). If she did not comply with her past heart disease medications, she would be at risk of developing ACS.