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Mr. H, Age 58, Male, White
CC: Chest Pain “Shortness of breath with severe pain on deep inhalation” (according to Dains, Baumann, & Scheibel, (2016) before a complete HPI is taken this patient must be a quickly assessed as this complaint can have rapid, life-threatening consequences).
HPI: Reports a constant chest pain for two days ago, taking a full breath makes it worst (inhalation), pain is sharp and severe with a current PIS of 8. Subject feel like his heart is racing. Nothing makes the chest pain better. The patient also has exhibited signs and symptoms of a cough, “spit up blood,” right leg swollen and red. He recalls being stationary for an eight-hour period while on a plane, in the economy section middle row, recently from vacationing in Europe, without bathroom overall usually has a sedentary lifestyle mostly due to working 9 am -5 pm as a customer service representative at a call center. After work he sits in front of the television and watches various programs for about four hours while eating dinner, drinking a can of beer or two and smoking a cigarette before bed. It started two days ago when the patient was running to clock in at work, to avoid being late.
Location: right chest pain
Onset: 2 days ago
Character: Sharp and constant
Associated signs and symptoms: a cough, elevated heart rate, and most recently expectoration of blood.
Timing: running to avoid being late for work
Exacerbating/ relieving factors: activity makes it worst. Nothing relieves the pain.
Severity: 8/10 pain scale
Current Medications: Hydrochlorothiazide 25 mg daily for six months, and Norvasc 5 mg twice daily from one month ago for hypertension, Lipitor 80 mg daily for high cholesterol; However, has not been compliant. The patient also stated that he was taking thiamin 100 mg, folic acid 250 mcg and vitamin D 5000 daily as supplements. Currently, he only takes ginseng to boost sexual performance.
Allergies: Patient is allergic to latex and mold both cause SOB chest tightening
PMHx: diagnose with hypertension and high cholesterol 10 years ago, left hip replacement 2 years ago. Immunization is up to date.
Soc Hx: Patient works at a call center as a customer service representative for the past thirty years. Married has no children. They live in their two-bedroom mortgage-free house. He currently smokes and has just reduced to 3 cigarettes per day after over forty years of smoking two packs per day. On the weekends he usually goes to the casino with his two college friends to gamble and have a good time. He has no special diet and will eat “anything from anywhere.” Drinks 2 six packs beer per week, and a bottle of vodka on weekends.
Fam Hx: His father died of lung cancer 15 years ago.
GENERAL: No weight loss, fever, chills, weakness or fatigue.
Head: Symmetrical, no swollen lymph nodes, no signs of sinus infection
Eyes: Does wear glasses due to myopia, no blurred vision, double vision or yellow sclerae.
Ear: No hearing loss.
Nose: Cough present, no congestion, runny nose.
Throat: No sore throat or difficulty swallowing.
SKIN: No rash or itching. Some redness and swelling to right leg.
CARDIOVASCULAR: Right side chest pain, chest pressure, and chest discomfort. Racing heart palpitations.
RESPIRATORY: shortness of breath, chest tightening, increased pain when inhaling, labored breathing.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Some frequency in urination, wakes twice at night to urinate.
NEUROLOGICAL: headaches and numbness and tingling of fingers. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No known history of splenectomy.
PSYCHIATRIC: Endorse feeling anxious
ENDOCRINOLOGIC: reports cold sweat
ALLERGIES: latex and mold
General: steady gait. Flushed face with a facial grimace. Appears anxious
Temperature: 97.9 oral
Respiratory rate: 32, labored
Heart rate: 112, tachycardic
BP right arm: 148/88
Oxygen saturation: 90% on room air
Weight: 210 lbs., stable
Skin: Cool, diaphoretic
Thorax and lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds to the left lung
Cardiovascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur or jugular vein distention.
Abdomen: Protuberant with normoactive bowel sounds auscultated x4 quadrants
Peripheral vascular: Right calf with 2+ edema, erythema; warmth and tenderness
on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally
Neurologic: Anxious; awake, alert, and oriented to person, place, and time
Diagnostic results: EKG shows Atrial fibrillation. He is waiting to do an angiography, chest x-ray and a ventilation/perfusion scan (V/Q) to examine blood flow in the lungs. Labs for collection are complete blood count, complete metabolic panel, lipid panel, troponin, creatinine kinase, creatine phosphokinase. D-dimer test to check for DVT and pulmonary embolism are needed, and a cardiac MRI to fully view the heart. (Dains, et al., loc 3494. 2016)
The provider states that the patient may have a pulmonary embolism. While this may be accurate, it is good to rule out other illnesses before giving a definitive diagnosis without proper analysis as misdiagnosis can cause a delay in treatment leading to great consequences. There are other possible differential diagnoses such as GERD, anxiety, and angina; however, listed below are three sudden, life-threatening differential diagnoses listed below.
Right side Congestive Heart Failure where according to Ball, Dains, Flynn, Solomon, & Stewart, (2015) the heart is unable to properly pump the blood to the body causing backflow to the lung and congestion in the heart. Hussein, A., & Staufenbiel, R. (2014) noted in their study of 59 cows with heart failures, that with right-sided heart failure the blood venous blood returning to heart is disrupted hence patient ends up with edema to the legs, shortness of breath, increased urination, rapid heartbeat which the patient is currently exhibiting and needs to be further investigated so proper treatment can be done.
Myocardial Infarction occurs due to the heart thickening thus causing decrease blood flow (Ball, et al. p.323. 2016). In Bahall, Seemungal, & Legall, (2018) controlled case study which focused on first time myocardial infarction in the same hospital in Trinidad and their risk factors. The writers look at the risk factors which includes diabetes mellitus, hypertension, hypercholesterolemia, smoking, alcohol consumption, obesity, and sedentary lifestyle, most of which is applicable Mr. H. the writers also reported with myocardial infraction no seen all over the globe therefore region, ethnicity and culture has no bearings on who may fall, victim, especially when they identify with one or more of the listed risk factors.
Pericarditis is when there is an inflamed pericardium due to infection. (Ball, et al. p.322. 2016). Per Dybowska, Kazanecka, Kuca, Burakowski, Czajka, Grzegorczyk, … Tomkowski, (2015) pericarditis is life-threatening and has a high death rate; urgent care is needed to prevent fatalities. While the patient does not have a fever the presentation of pericarditis symptom of chest pain, shortness of breath and chest pressure which the patient presents with should be completely ruled out as soon as possible.
Bahall, M., Seemungal, T., & Legall, G. (2018). Risk factors for first-time acute myocardial infarction patients in Trinidad. BMC Public Health, 18(1), 161. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-018-5080-y
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Dybowska, M., Kazanecka, B., Kuca, P., Burakowski, J., Czajka, C., Grzegorczyk, F., … Tomkowski, W. (2015). Intrapericardial fibrinolysis in purulent pericarditis–case report. International Journal of Emergency Medicine, (1), 1. https://doi-org.ezp.waldenulibrary.org/10.1186/s12245-015-0087-y
Hussein, A., & Staufenbiel, R. (2014). Clinical presentation and ultrasonographic findings in buffaloes with congestive heart failure. Turkish Journal of Veterinary & Animal Sciences, 38(5), 534–545. https://doi-org.ezp.waldenulibrary.org/10.3906/vet-1404-111
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