Chest Pain

CC:  “Chest Pain”

 

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HPI: 

Patient presents with complaints of chest pain that awoke her from sleep last night. Patient describes the pain as mid-sternal “squeezing, and pressure” with “tightness” radiating to her back. Patient reports that the pain was accompanied by diaphoresis. Episode lasted approximately 15-20 minutes at which time the pain spontaneously resolved. Reports she has experienced some intermittent attacks of chest pain and tightness approximately 2-3 times over the last six months, but that previous episodes were only a couple of minutes in duration, with less severe pain, and occurred while either walking the neighborhood or when she was “emotional”. Pain with prior episodes seemed to be relieved by rest. Pt. did not seek medical attention after previous episodes. Patient was unable to identify any alleviating factors associated with this episode. Aggravating factors with previous episodes included physical exertion, after eating a large meal (fried chicken), and emotional distress, but patient was not able to identify any precipitation or aggravating factors associated with last night’s chest pain. Patient denies experiencing any syncope, dizziness, shortness of breath, changes in pain with respirations, and cough. Patient denies change in diet or any unusual foods that evening. Patient denies headache. Denies vomiting but had some mild nausea last night.

 

PMH:

Positive for hypertension, hyperlipidemia, arthritis, uterine fibroids and GERD.  Denies history of asthma, allergies, cancer, diabetes, stroke, seizure disorder, myocardial infarction, bleeding disorders, urinary disorders, and depression.

Surgical history: Hysterectomy at age 50 r/t uterine fibroids

Psychiatric: Denies

Social History: Tobacco: 1.5 PPD smoker (should have asked for how many years in order to calculate pack years) ETOH use: occasional social drinking; drinks beer and liquor average 1-2 drinks per sitting Denies illicit drug use. Participates in monthly bowling league, but does not engage in regular aerobic or weight bearing exercises. Tries to eat a healthy diet.

Family History: Father died of heart attack at age 50. Mother 85 y/o is living, independent and in good health. Siblings both in good health. Sister had cholecystectomy at age 45. Denies family history of cancer, diabetes, stroke, kidney disease, neurologic disorders, stroke, bleeding disorders and mental illness.

Preventative Care: Immunizations: Influenza Fall 2014; Tetanus 2013

Current medications: RX: 1. HCTZ 25 mg PO daily

  1. Lipitor 20 mg PO daily
  2. Omeprazole 20 mg PO daily
  3. OTC: Denies

 

 

ROS:

GEN: Denies pain at this time, fatigue, fever, or weight changes.

HEENT: Denies HA, dizziness, sore throat, changes in vision or hearing. Does admit to mild burning in throat and occasional “sour” taste in mouth.

NECK: Denies neck pain, hoarseness, or difficulty swallowing.

CHEST: Denis cough, shortness of breath with exertion or at rest. Denies pain with inspiration or expiration.

CV: See details in HPI.

GI: Denies vomiting or change in bowel habits, but admits to nausea. Admits to recent belching. Has occasional epigastric pain.

GU: Denies dysuria, incontinence, or changes in voiding pattern.

MUSC: Denies joint pain or swelling.

NEURO: Denis headache, syncope, dizziness, muscle weakness or ataxia.

PV: Denies any extremity swelling or changes in temperature.

PSYC: Denies any changes in mentation or mood. Denies depression.

 

O

Temperature: 98.4 (oral), Pulse 90, Respirations 16, BP 160/94 Height: 68in. Weight: 201 lbs.

Waist Circumference: 40 inches BMI: 30.6 (obese);

BP recheck: 128/78 (lying), 132/82 (sitting)

Pleasant well, groomed female in no acute distress.

 

HEENT: Facial features symmetrical. Uvula midline, pharynx without erythema, edema or exudate. No odor noted. Pupils round reactive to light. No scleroicteris. Moist mucous membranes. TMs intact with good light reflex, canals clear. Nares patent. Turbinates moist/pink. Whispered word perceived at 5 feet. Vision 20/25 OU, OS, OD. No tenderness with palpation.

 

SKIN: Without lesions notes; turgor good; Warm & dry to touch. Hair distribution, texture, and quantity unremarkable. Nail beds pink.

 

NECK: Supple, non-tender, trachea midline. Thyroid non-enlarged, non-tender, without palpable mass or nodule. No lymphadenopathy. Full range of motion.

 

CHEST: Thorax without distortion, non-tender with symmetric expansion. Respiration regular and unlabored, without cough. Tactile fremitus equal bilaterally and greater in upper lung fields than lower.  Breath sounds clear with adventitious sounds. All lung fields with resonant percussion tones. AP ratio 2:1. No egophony, whispered pectoriloquy or bronchophony noted.

 

CV: Apical pulse not visible. Apical pulse palpable, approximately 1 cm at midclavicular line 5th ICS without thrill, lift or heave. RRR, Crisp S1 and S2 without extra heart sounds, murmur, rub, or gallop. NO apparent JVD. Bilateral carotid upstrokes brisk, without bruits.

 

EXTREMITIES: No clubbing or edema. No deformities noted. FROM actively and passively. No motor deficits.

 

ABDOMEN: Abdomen round, soft, and non-tender without rash, palpable mass or organomegaly. Active bowel sounds x4. Tympany over most quadrants with scattered areas of dullness noted upon percussion. Mild tenderness with palpation over the epigastric area and the RUQ. Lower supra-pubic surgical scar. No CVA tenderness.

 

PERIPHERAL VASCULAR: Skin pink, warm and dry and well perfused without edema, rash, or lesion. Nailbeds pink with <2 sec. capillary refill. No tropic skin changes or stasis changes noted. No abdominal bruits. 2 + dorsalis pedis pulses and radial pulses bilaterally.

 

NEURO: Patient alert, oriented, and appropriate. Moves all extremities well. Speech fluent and words are clear. Pt is coherent; cognition and insight appear intact. Strength 5/5 bilateral upper and lower extremities. Deep tendon reflexes 2+ throughout. Romberg normal, gait normal. Sensation equal to light touch. Distinguishes sharp-dull stimuli. CN I-XII intact:

I: Distinguishes smell of alcohol swab.

II: Visual Acuity- 20/20 with pocket screener, both eyes. Visual Fields- intact in all fields

II and III: PERRLA; peripheral vision intact

III, IV, VI: EOM- intact

V: Light Touch Face- in all 3 divisions of V; opening jaw strength normal

VII: Wrinkle Forehead, Close Eyes, Show Teeth; symmetrical

VIII:Whispered word at 5 feet heard

 IX & X:Swallowing intact; Uvula rise and fall with “AHHHH”

XI: Shrug Shoulders

XII: Protrude Tongue- midline protrusion

 

 

  1. Read the case scenario.
  2. Develop a differential list of the three most likely diagnoses. List these in priority of which you think is the most likely first.
  3. Write an explanation of the reasoning in choosing the most likely diagnosis.
    4. Write an explanation of the reasoning in choosing the two alternative diagnosis.

It must be in APA 7 , and must be at least 500 words.

You must have 2 supported sources from the literature in your initial response. Please note that APA requirements apply to all discussions and make sure to follow the discussion rubric.

Bullets 1-4 listed above are needed for the “initial post” of the discussion,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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