ASSESSMENT: Based on the information provided below, list your priority diagnosis. For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. References to be provided
SUBJECTIVE DATA: “ I have been having troubling chest pain in my chest now and then for the past month.
Chief Complaint (CC): chest pain
History of Present Illness (HPI): B.F is a 58 year old Caucasian male who presents to the office today with complaints of chest pain located over heart region. , occurring a few time over the last month with thoughts of possible heartburn. He describes the pain as being “tight and uncomfortable”. He rates the pain a 5/10 when present but currently has no pain. He reports the pain on two separate occasions, one being when he had to take the stairs at work due to the elevators being down and another when performing yard work. He reports that moving around makes the pain worst and more noticeable and relieve is obtained when sitting still to rest. He does not feel the pain is associated with anything that he eats. He denies trying any medication to help relieve the pain.
Medications: Lisinopril 20 mg daily for hypertension, Atorvastatin 20 mg daily for hypercholesteremia and Fish Oil supplement 1200 mg daily.
Allergies: Codeine with a reaction of N/V, no latex allergy, and no known food allergies
Past Medical History (PMH): Hypertension diagnosed about year ago. Hyperlipoidemia diagnosed about a year ago.
Past Surgical History (PSH): no past surgical history
Sexual/Reproductive History: Heterosexual relationship with his wife of 29 years.
Personal/Social History: denies tobacco use. No illicit drugs. Reports 2-3 beers on the weekend. Currently employed. Reports for exercise use to ride bike a lot until bike was stolen.
Immunization History: Reports all vaccines up to date and influenza vaccine current.
Significant Family History: Father- passed away at age 75 from Colon Cancer but had a history of high blood pressure and high cholesterol;. Mother aged 80 with high blood pressure and Type II Diabetes. One son age 26 in good health One daughter 19 with asthma. Maternal grandfather passed away in her mid-50’s of a heart attack. Maternal grandmother passed with breast Cancer in mid-50’s. Paternal grandfather passed away at age 85 of “old age”, otherwise healthy. Paternal grandmother passed away at age 80 from pneumonia
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: denies fevers, chills and night sweats. Denies fatigue no dizziness or light-headedness. Reports a weight gain of about 20 pounds over last couple of years.
Cardiovascular/Peripheral Vascular: reports episodic chest pain with tightness over mis-sternal chest area that does not radiate. Denies pressure or crushing sensation. Denies palpitations. Reports chest pan last “few minutes “.Rates chest pain 5/10 with activity. Denies heart murmur and no edema Reports recent EKG was normal as well as Stress Test
Respiratory: denies cough and reports no shortness of breath
Gastrointestinal: denies nausea or vomiting. No reports of constipation. No abdominal pain. Report the chest pain was thought of as “heartburn.” Denies gassiness and bloating. No difficulty eating or swallowing.
Musculoskeletal: reports no joint pain, No problems ambulating. Reports able to get around without use of assistive device. . No change in gait,
Psychiatric: Denies anxiety or depression. No report of suicide ideation and no auditory or visual hallucinations.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Ht 5’7 Wt 197 lbs. B/p 146/90 HR 104 RR 19 Temp 36.7C O2 saturation 98% on room air
General: I Alert and oriented to place time day and situation. Answers questions appropriately. Dress according to the weather. Upright posture maintained during interview. No acute distress noted during examination process.
Cardiovascular/Peripheral Vascular: no JBD present, S1, S2 and S3 audible with gallop noted in mitral valve. Nails and toes beds with capillary refills less than 3 seconds. No edema noted to BLE. Right carotid artery with bruit +3. PMI displaced laterally, brisk and tapering <3 cm. EKG performed showing NSR with no ST changes.
Respiratory: chest symmetric with regular breathing and rate with use of accessory muscles. Breath sounds present in all lobes with fine crackles noted posterior lower right and left lobes.
Gastrointestinal: abdomen soft, rounded, non-tender on light and deep palpitation. No masses noted. Abdominal sound normoactive in all quadrants. No friction rub noted to liver or spleen. Spleen, right and left kidney not palpable
Musculoskeletal: steady gait. Maintain good posture. No abnormalities noted.
Neurological: no memory loss, present calm with no signs of anxiety
Skin: warm and dry with no tenting. No color changes noted. No visible rashes, bruising or skin lesions.
Diagnostic Test/Labs: Chest X-Ray to look for possibilities on aortic aneurysm or any other abnormal findings. Echocardiogram to assess heart rate and rhythm thought ultrasound to assure that there are no defects in the heart that may be contributing to the chest pain. Exercise Stress test to evaluate how the heart responds to exercise. Venous Doppler Study to look at the circulation in the legs to determine what could be causing bilateral diminished pulses. Report EK to re-evaluate for any new heart abnormalities. CBC to assess for possible anemia. CMP to evaluate for potential of electrolyte imbalance. Troponin/Cardiac enzymes to evaluate heart muscle when a heart attack is in question.
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.
