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HPI: 60yo African American male who reports feeling SOB and a heavy feeling in his chest, with nausea and sweating 3 days ago. The episode lasted about 3 minutes. He denies subsequent episodes. C/o fatigue since the event.
PMH: Hypertension, hyperlipidemia, both managed with lifestyle. Reports general good health. Childhood illnesses: chicken pox. Surgical Hx: T&A, cholecystectomy, vasectomy. Hospitalizations: none except for surgeries mentioned. No blood transfusions. Food/drug allergies: NKA. Immunizations: does not receive flu shot. Current medications: None.
FH: Parents deceased: Father died from lung cancer; mother from CVA complications.
Brother died at 44yo d/t malignant melanoma. Other sister and brother are healthy.
SH: Married x 20 years, works as architect. Drinks a beer or glass of whiskey and smokes occasional cigar when playing poker with friends. Was exercising regularly until 3 days ago.
ROS: Constitutional: Reports intentional weight loss d/t working out. Reports fatigue x 3 days, especially when working out. HEENT: no report of HA, changes to vision or hearing, pain to eyes or ears, ringing in ears, nasal congestion, sneezing, epistaxis, ST, or difficulty swallowing.
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CV: reports heavy feeling in chest 3 days ago, lasted 3 minutes, resolved. No further episodes. No report of DOE, palpitations or peripheral edema. Resp: reports SOB during CP episode. No report of cough or sputum. GI: reports nausea during CP episode 3 days ago, resolved. No report today of N/V/D, constipation, heartburn, or decreased appetite. GU: no report of urinary hesitancy, frequency, burning, or urgency. MS: does not report muscle pain, joint swelling, pain or stiffness, or back pain.
Derm: does not report pruritis, rash, new lesions, or change in skin color. Neuro: does not report dizziness, fainting, numbness or tingling in extremities, change in bladder or bowel control. Psych: does not report anxiety or depression. Endo: no report of polyuria, polydipsia, polyphagia, sweating, or heat/cold intolerance. Allergies/Immun: No report of hx asthma or allergies.
0: Ht. 68in Wt. 220lbs (99.8kg), BMI: 33.5 BP 146/90, T not recorded, P 70, R 18, SaO2 98% on RA.
General: 60yo African American male, appears stated age, NAD. Alert, oriented, and cooperative. Pain: 0/10 at present. Skin: warm, dry, intact; skin color light-skinned brown, no cyanosis or pallor. No rashes or vesicles noted on chest. HEENT: head normo-cephalic. Hair thick, distribution even through scalp. Eyes: sclera clear, conjunctiva white; PERRLA, EOMs intact. No AV nicking noted. Ears: TMs gray and intact, light reflex noted; pinna and tragus non-tender. Nose: nares patent without exudate. Sinuses non-tender to palpation; right-sided deviation. Throat: OP moist, no lesions or exudate. Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes from midline. Neck: supple, no cervical lymphadenopathy or tenderness noted. Thyroid midline, small, firm, no palpable masses. Mild JVD noted in recumbent position. Resp: lungs CTA bilaterally; respirations unlabored. CV: Heart S1 and S2 noted, RRR, no murmurs noted. No parasternal lifts, heaves, or thrills. PMI 5th ICS displaced 4cm laterally. Peripheral pulses equal bilaterally, no peripheral edema noted. Abdomen: round, soft, BS noted in all 4 quadrants; no organomegaly noted.
Diagnostic testing: Lipid profile (3 mo ago): Total Chol 230; LDL 180; HDL 38.
A: Acute Coronary Syndrome (ICD I24.9)
(Smith, Negrelli, Manek, Hawes & Viera, 2015)
Dyslipidemia (ICD E78.5)
(Grundy et al., 2018)
Hypertension (ICD I10)
(Carey & Whelton, 2018)
(Garvey, 2018)
P:
Rx:
325mg non-enteric coated ASA. Sig: administer now. Disp 1 tab, RF: 0
(Amsterdam et al., 2014)
To pick up after ED evaluation:
Lisinopril 10mg, Sig: 1 tab po QD, Disp 30, RF: 1
(Amsterdam et al., 2014)
Metoprolol tartrate 50mg, Sig: 1 tab po BID. Disp 60, RF: 1
(Amsterdam et al., 2014)
Atorvastatin 40mg, Sig: 1 tab po QHS. Disp 30, RF: 1
(Amsterdam et al., 2014)
Aspirin- non-enteric coated 81mg, Sig: 1 tab po QHS. Disp 30, RF: 1
(Amsterdam et al., 2014)
Nitroglycerin 0.3mg, Sig: 1 tab SL as needed for chest pain that does not stop within 5 minutes. May use 1 every 5 minutes up to 3 tabs. Call 9-1-1 or go to ED if use more than 1 tab. Disp 6, RF: 1
(Amsterdam et al., 2014)
Additional diagnostic tests (to be done in Emergency Department):
Serial cardiac troponin enzymes q4-6h
BNP
Lipid profile
Additional tests (CBC, CMP, EKG, CXR, echo) at discretion of ED attending
(Amsterdam et al., 2014; Smith et al., 2015)
Patient informed of his diagnosis and urgent need to go to emergency department immediately for further evaluation and monitoring. Brief explanation of diagnostic tests, possible treatments and anticipated discharge medications, along with potential side effects provided (Amsterdam et al., 2014).
Instructed to call 9-1-1 for CP, DOE, nausea, sweating, irregular heartbeats, syncope or other cardiac symptoms if they occur after discharge from ED (Amsterdam et al., 2014).
May take 1 tab nitroglycerin SL q 5mins x 3 for CP that does not resolve after 1 minute. Call 9-1-1 if two or more doses are needed (Amsterdam et al., 2014).
Patient will follow-up with cardiology. Informed patient that the cardiologist will order cardiac rehabilitation and might adjust medications (Amsterdam et al., 2014). Informed patient that I will be in touch with cardiologist to coordinate care.
Follow-up with primary care after cardiology appointment to recheck blood pressure, review response to medications and coordinate care (Amsterdam et al., 2014).
Pneumococcal and influenza vaccine administration planned at follow-up visit if no contraindications at that time (Amsterdam et al., 2014).
Dietary, physical activity, and smoking lifestyle modifications to reduce cardiac risk factors will be reviewed at follow-up visit (Amsterdam et al., 2014).
ED now (Amsterdam et al., 2014).
Cardiology for ongoing specialized evaluation and management (Amsterdam et al., 2014).
With cardiology within 1 week of discharge from ED or hospital (Amsterdam et al., 2014).
With PCP in 1 month to assess BP, response to medications and any adverse medication effects (Carey & Whelton, 2018).
Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R. . . . Zieman, S. J. (2014. AHA/ACC guidelines for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64(24), 2645-2687. doi: 10.1016/j.jacc.2014.09.016
Carey, R. M., & Whelton, P. K. (2018). Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Annals of Internal Medicine, 168(5), 351-358. doi: 10.7326/M17-3203
Garvey, W. T. (2018). The diagnosis and evaluation of patients with obesity. Current Opinion in Endocrine and Metabolic Research,1-8. doi:10.1016/j.coemr.2018.10.001
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Bumenthal, R. S., Braun, L. T. . . . Yeboah, J. (2018). AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the Aermcian College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. DOI: 10.1161/CIR.0000000000000624.
Smith, J. N., Negrelli, J. M., Manek, M. B., Hawes, E. M. & Viera, A. J. (2015). Diagnosis and management of acute coronary syndrome: An evidence-based update. Journal of the American Board of Family Medicine, 28(2), 283-293. doi: 10.3122/jabfm.2015.02.140189
The Diagnostic Process of Patient. (2019, Dec 14). Retrieved from https://studymoose.com/the-diagnostic-process-of-patient-essay
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