Case Study I-human Florence Blackman CC 66 Year-old Female – Chest Pain Complete Solutions Graded A

Case Study I-human Florence Blackman CC 66 Year-old Female – Chest Pain Complete Solutions Graded A

NUR 6104-Florence Blackman, Ramona

Frankel, Ben Kapinsky Complete new Ihuman

cases-complete 2022

Florence Blackman (66 y/o female) – Chest Pain

• CC: Intermittentsqueezing chest pain

• MSAP: Exertional “squeezing” mid-chest pain radiating to left arm, relieved by rest,

worse with cold

• Associated dyspnea on exertion

• History: HLD, HTN, previous smoker, family hx of heart disease

• Stressful work

History Questions:

- How can I help you today?

- Any other symptoms we should discuss?

- Do you have any allergies?

- Are you taking any OTC or herbal medications?

- Any new or recent changes in medications?

- What does the pain / discomfort in your chest feel like? (squeezing, pressure, crushing,

burning, stabbing, aching, tingling, suffocating)

- How severe (scale 1-10) is the pain in your chest?

- Does anything make the pain in your chest better or worse?

- What are the events surrounding the start of your chest pain?

- Is there a pattern to your chest pain?

- Have you had any trauma to your chest?

- Does the pain in your chest radiate someplace else? Where?

- Do you have unusual heartbeats(palpitations)?

- Does the pain get worse with breathing?

- Does your pain awaken you from your sleep?

- Is your pain affected by what, when, or how much you eat?

- Do you presently have heartburn, a food or acid taste in your mouth?

- Do you drink alcohol? If so, what do you drink and how many drinks per day?

- Do you have any of the following problems: fatigue, difficulty sleeping, unintentional

weight loss or gain, fevers, night sweats?

- Do you experience: SOB, wheezing, difficulty catching breath, chronic cough, sputum

production?

- Does anything make your shortness of breath better or worse?

- How long does your SOB last?

- Do you have any of the following: heat or cold intolerance, increased thirst, increased

sweating, frequent urination, change in appetite?

- Do you have any of the following: dizziness, fainting, spinning room,seizures, weakness,

numbness, tingling, tremor?

- Do you have problems with: N/V, constipation, diarrhea, coffee groundsin your vomit,

dark tarry stool, bright red blood in your BM, early satiety, bloating?

- How is your overall health?

- Tell me about your work.

- Tell me about daily exercise or sportsthat you play.

Physical Exam:

- Vitals: pulse, BP, respirations

- Examine skin

- Neck: measure JVP (jugular venous pressure)

- Neck: auscultate carotid arteries

- Chest wall & lungs:

o Visual inspection of anterior & posterior chest

o Palpate anterior & posterior chest

o Auscultate lungs

- Heart:

o Palpate for PMI (Point of Maximal Impact)

o Auscultate heart

- Abdomen:

o Auscultate abdominal/femoral arteries

o Palpate abdomen

- Extremities: Visual inspection of extremities

Assessment note:

- F.B. is a 66 y/o Caucasian female presenting with 2-week h/o new onset, intermittent,

stable chest pain which radiates to the L arm, occurs with SOB, is worse with cold

temperatures and exertion, and improved by rest. On physical exam she is pain free with

stable vital signs. PMH risk factors include: distant history of smoking (5 pack/years), a

history of HTN, and high cholesterol, and a family history of coronary vascular disease.

- Stress test: 2-mm ST segment depression in inferior leads, 2, 3, and aVF and V3-6

Diagnosis: Coronary artery disease: stable angina

Plan:

- Determine need for coronary angiography based on stress test results and ECHO. Her

Duke score of 10.5 is slightly above moderate risk, and arguments could be made for

both a trial at medication intervention since the pt needs improvement on both HTN and

HLD

o Augment management of preexisting HTN and HLD with a BB (metoprolol 25 mg

XR daily); a statin (atorvastatin 40 mg daily); and ASA 81 mg daily

- Continue use of HCTZ 25 mg daily

- Encourage lifestyle modification:

o Decrease intensity of aerobic workouts for next 3 months

o D/c alcohol for next 2 months as starts a statin

- f/u in 3-4 weeks

Ben Kapinsky (18 y/o male) – Fever

• CC: Fatigue, SOB, productive cough with yellow/green sputum

• MSAP: Hypoxia

• Tachypnea, dyspnea

• Fever and chills

• Fatigue and myalgia

• Right-sided chest wall pain aggravated by coughing

• Productive cough

• Right middle and lower lung crackles

• Bilateral cervical lymphadenopathy

• Tachycardia

• Previous hx of the flu 2 weeks ago, but got better

• Childhood asthma per history

History Questions:

- How can I help you today?

- Any other symptoms or concerns we should discuss?

- Do you have any allergies?

- Are you taking any prescription medications?

- Are you taking any OTC or herbal medications?

- How high is your fever?

- When did your cough start? – 4 days ago

- Is there a pattern to your cough? – no

- Does anything make your cough better or worse?

- Are you coughing up any sputum? – yellowish green stuff

- What are the events surrounding the start of your cough? – symptoms started without

much warning, thought maybe just got tired going to the party, but got worse over time

- What treatments have you had for your cough? – cough syrup, doesn’t help

- Do you awaken at night coughing? – yes, can’t sleep

- Have you had a cough like this before? – no

- Do you have any pain in your chest? – yes, here on the right side when I cough or take a

deep breath (points to right thorax, 6-8th intercostal space at midaxillary line)

- How severe (1-10 scale) is the pain in your chest? – 7-8 when cough or deep breathe

- Have you had any contact with other sick people? – no

- Tell me about any current or past medical problems? – none besides mild asthma

- Any previous medical, surgical, or dental procedures? – none besides fillings in teeth

- Have you ever been hospitalized? – no

- Do you have any of the following problems: fatigue, difficulty sleeping, unintentional

weight loss or gain, fevers, night sweats? – “some of that stuff for sure”

- Do you have any problems with: headaches that don’t go away with ASA or Tylenol,

double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus

problems, chronic sore throats, difficulty swallowing?

- Do you experience: chest pain discomfort or pressure; pain/pressure/dizziness with

exertion or getting angry; palpitations; decreased exercise tolerance; blue/cold fingers or

toes?

- Do you have problems with: N/V, constipation, diarrhea, coffee groundsin your vomit,

dark tarry stool, bright red blood in your BM, early satiety, bloating?

- When you urinate, have you noticed: pain, burning, blood, difficulty starting orstopping,

dribbling, incontinence, urgency during day or night or any changes in frequency?

- Do you have problems with: muscle or joint pain, redness, swelling, muscle cramps, joint

stiffness, joint swelling or redness, back pain, neck or shoulder pain, hip pain?

- Have you noticed: any bruising, bleeding gums, nose bleeds, or other sites of increased

bleeding?

- Do you have any of the following: heat or cold intolerance, increased thirst, increased

sweating, frequent urination, change in appetite?

- Do you have any of the following: dizziness, fainting, spinning room,seizures, weakness,

numbness, tingling, tremor?

- Do you have any problems with nervousness, depression, lack of interest, sadness,

memory loss, or mood changes, or even hear voices or see things that you know are not

there?

- Do you drink alcohol? If so, what do you drink and how many drinks per day? –

occasional beer or wine after studying

- Do you use any recreational drugs? – no

- Do you now or have you ever smoked or chewed tobacco? – no, athletic

- Are you sexually active? – no

- Do you have HIV?

Physical Exam:

- Vitals: Temp, pulse, BP, orthostatic BP, respirations

- Skin, hair, nails: inspectskin overall – tenting of dorsal hand skin (dehydration)

- HEENT: inspect mouth/pharynx

- Neck: palpate neck

- Lymphatic: palpate all lymph nodes – tender cervical lymph nodes on neck

- Chest wall & lungs: auscultate lungs

- Heart: auscultate heart

- Abdomen:

o Visual inspection

o Palpate

- Extremities: visual inspection

- Genitourinary: male exam

- Musculoskeletal:

o inspect for muscle bulk and tone

o teststrength

- Neurological:

o cranial nerves

o reflexes – deep tendon

Assessment note:

- Ben Kapinsky is a 18 y/o college student who presents with a hx of the flu which

resolved and then was followed by a 4-day history of sudden onset fevers, chills, SOB,

fatigue, pleuritic chest pain, and a productive cough without wheezing. Physical exam is

significant for a fever of 103.2 F (oral), tachypnea (24 breath/min), hypoxia, and R middle

and lower lobe coarse crackles, and tender anterior cervical lymphadenopathy. He

denies known sick contacts and has a childhood hx of asthma, now off therapy without

recent attacks.

Diagnosis: Community acquired bacterial pneumonia

Plan:

- Admit to the student health center inpatient service

- Oxygen PRN

- IV fluids

- IV antibiotics

- Respiratory therapy as needed if he develops an asthma exacerbation

Ramona Frankel (6 y/o female) – Red Right Eye

• CC: came in with mother complaining of red right eye for past 3 days

• MSAP: right eye redness

• Right eye discharge

• Other children at school with similar symptoms

• Congestion

History Questions:

- How can I help you today? – mom

- Any other symptoms or concerns we should discuss? – mom

- Does she have any allergies? – mom

- Is she taking any prescription medications? – mom

- Is she taking any OTC or herbal meds? – mom

- What treatments has she had for her eye problem? – mom

- Are there any other people she has had contact with who have a similar eye problem? –

mom

- Has she had any trauma to her eyes? – mom

- Does she have any pain in her eyes? – mom

- Has she noticed any blurred vision? – mom

- Does she have a runny nose/nasal congestion? – mom

- Does she have a cough? – mom

- Tell me about any current or past medical problems? – mom

- Any previous medical,surgical, or dental procedures? - mom

- Are her immunizations up to date? – mom

Physical Exam:

- Vitals: temp, pulse, BP,respiration

- HEENT:

o inspect eyes

o test visual acuity

o examine pupils

o look in ears with otoscope

o inspect mouth/pharynx

o look up nostrils

- Chest wall & lungs: auscultate

- Heart: auscultate

Assessment note:

- Ramona is a 6 year old female with right eye redness and purulent drainage for the last 3

days. She was sent home from school today along with other children who had similar

symptoms. She has also had some nasal congestion for the last few days. She has not

had any fevers or trauma to the eye. Physical exam is significant for right conjunctival

redness and purulent discharge. Mother is requesting a clearance to return to school.

Diagnosis: Bacterial conjunctivitis(pink eye)

Plan:

- 7-10 days of antibiotic eye drops

- Instruct patient/parent about handwashing, and educate to not rub eyesto prevent

spread of infection

- Children can return to school 24 hrs after starting treatment

- If symptoms worsen or if child has eye pain or blurry vision, return to clinic or ER