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NURS 6512 Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

NURS 6512 Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

Walden University NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System-Step-By-Step Guide

 

This guide will demonstrate how to complete the Walden University  NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

 

How to Research and Prepare for NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

 

Whether one passes or fails an academic assignment such as the Walden University  NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

 

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

 

How to Write the Introduction for  NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

 

The introduction for the Walden University  NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

 

How to Write the Body for  NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System 

 

After the introduction, move into the main part of the  NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

 

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

 

How to Write the Conclusion for  NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

 

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

 

How to Format the References List for  NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

 

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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SUBJECTIVE DATA: 

Mr. Brian Foster is a 58 years old male who presented at the emergency department with complaints of  acute chest pain at the mid-sternum of the chest. The pain is tight and uncomfortable, aggravated by movement up the stairs and exertion. The pain is relieved by rest. The chest pain is periodic and lasts a few minutes. He has had three episodes of pain in one month. He denies coughing, shortness of breath, indigestion, fatigue, dizziness, weakness, nausea, vomiting, heartburn, orthopnea, and syncope.

Chief Complaint (CC):  “I’ve been experiencing this tight, uncomfortable feeling in my chest every now and then. I’m starting to worry it could be something serious.”

History of Present Illness (HPI): Brian Foster is a 58-year-old Caucasian male who came in for chest pain, which occurred three times in the past month. He reports that the pain is right in the middle of the chest, over the heart, and does not radiate. He describes the pain as tight and uncomfortable, with a pain scale of 5 out of 10. But currently, he is not experiencing any pain. He states that the pain started earlier this month when he was doing his yard work. The pain has a sudden onset, and is aggravated by physical activities such as yard work and taking stairs, and relieved by brief rest such as lying still. He denied taking any medications for the chest pain. According to him, the pain is not related to any food consumption nor stress. The pain usually lasts a couple of minutes.

Medications: Lisinopril (Prinivil) 20mg PO Daily, high blood pressure. Atorvastatin (Lipitor) 20mg PO daily at bedtime, hyperlipidemia . Omega-3-Fish Oil 1200mg PO BID. Tylenol and Ibuprofen for pain as needed.

Allergies:  Codeine- Nausea and vomiting

Past Medical History (PMH):  Hypertension -Diagnosed a year ago. Hyperlipidemia- a year ago

Past Surgical History (PSH): No past surgical history noted

 

Sexual/Reproductive History: Married to wife for 27 years. Has 2 children

Personal/Social History: Lives at home with wife and daughter visits frequently. Patient currently works as a civil engineer. Denies tobacco use. Denies marijuana, cocaine, heroin, or other illicit drug use. Reports social drinking 2-3 alcoholic beverages of beer per week. Reports eating three meals a day Patient   reports   generally   low   stress   lifestyle.   Denies   regular   exercise   routine   currently.   Last   regular exercise was two years ago.  Reports seeing healthcare providers every 6 months. Last visit was roughly 3 months ago. Has a primary care doctor. Has no financial issues.

Immunization History: Tdap 10/2014, Flu vaccine received for the season

Significant Family History:

Mother: type 2 diabetes, hypertension, age 80

Brother: died age 24 in motor vehicle accident

Sister: type 2 diabetes, hypertension, age 52

Maternal grandfather: died of heart attack, age 54

Maternal grandmother: died of breast cancer, age 65

Paternal grandmother: died of pneumonia, age 78

Paternal grandfather: died of old age at 85

Son: healthy, age 26

Daughter: asthma, age 19

NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

NURS 6512 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

Subjective Data

Patient Particulars

Name: Mr. foster

Age: 58years

Gender: male

Race:

Chief complaint: “I have been having some trouble with chest pain for the past month

History of presenting illness: Mr. Foster presents at the emergency department complaining of chest pain in the mid-sternum region. It is intermittent, tight, and uncomfortable lasting for a short time. It is of acute onset aggravated by meals and exertion and relieved by rest. However, the pain does not radiate. It is associated with mild leg cramping the patient denies coughing, shortness of breath, indigestion, heartburn, jaw pain, dizziness weakness, nausea, vomiting, diarrhea, anxiety, and emotional stress.

Past medical history: the patient has hypertension, hyperlipidemia, and diabetes mellitus

Surgical history: none

Allergies: he is allergic to dust, fur, and cold weather. He develops a skin rash and itchiness and relieves it by taking prednisolone. He has no food and drug allergy.

Medication: metformin 1g PO BID, amlodipine 10mg PO OD, atorvastatin 20mg PO OD

Immunization: the patient’s immunization schedule is up to date. His last influenza and pneumococcal vaccines are six months and three months ago respectively. He is yet to get a tetanus toxoid booster.

Social history: Mr. foster works as an operations manager in a bank. She has studied up to a master’s degree in finance. He is married, has two children, and stays with them. He enjoys reading novels and watching documentaries. His diet includes grilled red meat about five times a week, vegetables, and sandwiches. Occasionally, he takes fast food for lunch on a busy day with 1-2cups of coffee a day. He smokes at least cigarettes per day. He takes two bottles of beer daily and a bottle of whisky over the weekend. He does not engage in physical exercise.

Family history: the patient is the firstborn in a family of three siblings. His mother has hyperlipidemia, hypertension, and osteoarthritis. His father has obesity, diabetes mellitus, coronary heart disease, and hypertension. His paternal grandfather died six years ago due to acute myocardial infarction and his grandmother died ten years ago due to diabetes mellitus. His maternal grandparents are living with senile dementia. His younger sister 40 years has hypertension. His younger brother, 35years old has hyperlipidemia and diabetes mellitus. His children have no major chronic illnesses. However, there is no history of lung or breast cancer.

Review of systems:

General: the patient denies fatigue, weight loss, night sweats, and fever.

HEENT: The patient denies headache, dizziness, eye itchiness, ear pain, sore throat, and running nose.

Respiratory system: the patient denies coughing, running nose, difficulties in breathing, wheezing, and sputum production.

Gastrointestinal system: the patient denies abdominal pain, reflux, heartburn, nausea, vomiting, diarrhea, constipation, and Malena stool.

Genitourinary system: the patient denies hematuria, dysuria, polyuria, flank pain, vaginal discharge, dyspareunia, and urine incontinence.

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Neurological: the patient denies paralysis, numbness of extremities, facial droop, and tingling sensation.

Musculoskeletal system: the patient reports mild cramping of the legs. However, he denies joint pain, muscle pain, stiffness, muscle spam, fracture, and dislocation.

Hematological system: the patient denies easy bruising, frequent infections, fever, and bleeding tendencies.

Lymphatic system: the patient denies lower limb edema, recurring infections, skin fibrosis, and lymph nodes.

Skin: the patient denies skin rash, stretch marks, and itchiness.

Endocrine: patient denies weight fluctuation, weakness, fatigue, heat and cold intolerance, and mood swings.

Objective Data

General examination: the patient is alert and oriented. he has a clear speech sitting comfortably with no acute distress.

Vitals: blood pressure 164/88, pulse rate 94beats per minute, the temperature at 36.5, height 151cm, weight 78kg, and BMI 34.21kg/m2.

Cardiovascular system: S1 S2 noted with no murmurs or rubs. S3 is noted at the mitral area and the PMI is displaced laterally at the mitral area.

Peripheral vascular: there is no JVD present. JVP is 3cm above the sternal angle. The left carotid has no bruit. There is a right carotid bruit with a 3+ thrill. The brachial, femoral, and radial pulses have no thrill. The capillary refill is less than 3sec in all four extremities.

Respiratory: the breathing is quiet and unlabored. The breath sounds are clear to auscultation in the upper and lower lobes. There are fine crackles in the posterior base of the right and left lungs.

Gastrointestinal: the abdomen is soft, round, and non-tender with normal-active bowel sounds in all the four quadrants. There are no abdominal bruits and tenderness to light and deep palpation. The liver span is 7cm at the MCL and 1cm below the costal margin. There is a tympanic percussion note throughout. The spleen and bilateral kidneys are not palpable.

Skin: the skin is warm, dry, pink, and intact. There is no tenting and sweating.

Neurological: the patient is alert and oriented. She follows commands, moves all the extremities, and the gross cranial nerves are intact.

Musculoskeletal: The patient moves all the extremities.

Psychiatric: the patient is cooperative, maintains eye contact, and has a normal affect.

EKG: the patient has a regular sinus rhythm. There are no ST changes.

Assessment

The patient presents with chest pain and mild leg cramping on exertion. He has hypertension, hyperlipidemia, and diabetes mellitus. The patient is obese and has diminished carotid pulse and bruits. He has an S3 in the mitral region. He leads a sedentary lifestyle. He smokes and takes alcohol every day. He has a positive family history of diabetes mellitus, hypertension, hyperlipidemia, myocardial infarction, and coronary heart disease. The differential diagnoses are angina pectoris, coronary heart disease, and congestive cardiac failure.

Angina pectoris is an imbalance of myocardial blood supply and demand. It is common in patients with coronary arteries. The main presenting complaint is chest pain. the pain is in the epigastric region or retro-sternal region and it feels very tight. The pain is precipitated by exertion, meals, and emotional stress lasting for about 5minutes. The patient does not change in respiration. Risk factors are atherosclerosis, metabolic syndrome, severe anemia, and hyperthyroidism (Webb, C. M., & Collins, P. 2021). This is the probable diagnosis because the patient presents with intermittent chest pain on exertion and after meals. He has metabolic syndrome because of obesity, hyperlipidemia, hypertension, and diabetes mellitus. Additionally, he has atherosclerosis because of the reduced carotid pulses and bruits.

Coronary heart disease is a disease of the blood vessels characterized by endothelial dysfunction, vascular inflammation, build-up of lipids, cholesterol, and calcium and cellular debris in the vessel wall. This causes plaque formation, luminal obstruction, and reduced oxygen supply to the target organs. Clinical signs and symptoms are epigastric pain postprandial, neurological deficits, intermittent claudication, and weight loss (Cushman, et al, 2021). The patient often presents with hyperlipidemia, diminished carotid pulse and bruits, peripheral cyanosis, and gangrene. However, this is not the actual diagnosis because the patient does not have cyanosis, weight loss, and gangrene.

Congestive heart failure is the inability of the heart to pump blood at a rate that commensurates the demand of the metabolizing tissues. The patient presents with exertional dyspnea, orthopnea, edema, tachycardia, fatigue, oliguria, distended neck veins, wheezing, and hepatojugular reflux (Koehler, et al, 2021). However, this is not the actual diagnosis because the patient does not meet the Framingham criteria for heart failure. It comprises paroxysmal nocturnal dyspnea, neck vein distension, acute pulmonary edema, cardiomegaly, and S gallop.

Plan

Diagnostic tests

  1. Chest radiograph to rule out cardiomegaly or cardiomyopathy
  2. CT angiography demonstrates an anatomical assessment of the hemodynamic significance of coronary stenosis.
  3. Exercise stressing tests help evaluate the chest pain
  4. Cardiac enzymes rules out cardiomyopathy
  5. Complete blood count to rule out anemia
  6. A1C determines the patient’s diabetes control for three months
  7. The lipid profile checks the level of triglycerides.

Pharmacological treatment

  1. Aspirin 81mg PO OD
  2. Atorvastatin 40mg PO OD
  3. Losartan 50mg PO OD
  4. Nitroglycerine 6.5mg PO TDS
  5. Metformin 1g PO BD

Non-pharmacological

  1. Lifestyle modification
  2. Refer the patient to the physician and cardiologist

References

Cushman, M., Shay, C. M., Howard, V. J., Jiménez, M. C., Lewey, J., McSweeney, J. C., … & American Heart Association. (2021). Ten-year differences in women’s awareness related to coronary heart disease: results of the 2019 American Heart Association National Survey: a special report from the American Heart Association. Circulation143(7), e239-e248.

Koehler, J., Stengel, A., Hofmann, T., Wegscheider, K., Koehler, K., Sehner, S., … & Laufs, U. (2021). Telemonitoring in patients with chronic heart failure and moderate depressed symptoms: results of the Telemedical Interventional Monitoring in Heart Failure (TIM‐HF) study. European journal of heart failure23(1), 186-194.

Webb, C. M., & Collins, P. (2021). Medical management of anginal symptoms in women with stable angina pectoris: A systematic review of randomised controlled trials. International Journal of Cardiology341, 1-8.

SUBJECTIVE DATA:

Chief Complaint (CC): “I have sporadic chest pain”

History of Present Illness (HPI): Mr. J.M. is a 38-year-old African American male who presented to the emergency department with complaints of sporadic chest pain for the last one month. The pain is usually centrally located and radiates to the left arm. He has experienced 3 episodes since the last month with each episode lasting several minutes. Currently, the pain is at 0 on a scale of zero to 10 although it is generally at 5 at its worst. The pain is characteristically uncomfortable and tight. It is aggravated by activities such as climbing stairs and yardwork while brief episodes of rest relieve the pain. He has not taken any medications for the pain.

Medications: Reports taking Lopressor 100mg PO once daily for hypertension and Lipitor 20mg PO once daily for hyperlipidemia as well as fish oil 1000mg PO twice daily.

Allergies: None

Past Medical History (PMH): Reports hypertension and hypercholesterolemia. No previous hospitalizations or blood transfusions. Denies prior chest pain treatment. Poor blood pressure monitoring both at home. Denies regular blood pressure checks at the pharmacy and drug store. Reports a recent EKG test that was normal. His last visit to a healthcare provider was three months ago.

Past Surgical History (PSH): No previous surgeries.

Sexual/Reproductive History: Heterosexual.

Personal/Social History: Has lived a relatively stress-free lifestyle. Regular water intake of about a liter per day. Drinks 2 cups of coffee daily. Denies routine regular physical activity and his last regular exercise was 2 years ago. Reports moderate alcohol consumption of about 2 to 3 drinks per week mostly on weekends but no tobacco or illicit drug use. His typical breakfast is a granola bar and instant breakfast shake, lunch turkey sub, and his dinner is typically grilled meat alongside vegetables.

Immunization History: All immunization up to date. The last COVID-19 vaccine was February this year, the last Tdap was May 2022 and the last influenza was January 2022.

Significant Family History: His mother is 65 years old and hypertensive while the father is 70 years old and obese. The grandmother died at 77 years due to a heart attack while the grandfather is 85 but suffered a stroke at 80 years. He has two daughters all alive and well.

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Review of Systems:

General: Denies fever, changes in weight, chills, fatigue, night sweats, and palpitations.

            Cardiovascular/Peripheral Vascular: No edema, easy bruising, angina, or easy bleeding.

            Respiratory: No difficulty in bleeding, sputum, cough, or shortness of breath.

            Gastrointestinal: Denies alteration in bowel habits, abdominal pain and nausea, and vomiting

            Musculoskeletal: No back pains, joint pains, and muscle weakness.

            Psychiatric: No anxiety, depression, delusions, or hallucinations

 

OBJECTIVE DATA:

Physical Exam:

Vital signs: Temperature- 98.5 F, pulse 80 beats per min, respiratory rate- 19 breaths per minute, blood pressure- 132/86 mmHg, saturation- 92% on room air, height 70. 86 inches, weight 251 lbs. BMI- 29.

 

General: A young African American male, well kempt and groomed, and appropriate for his stated age. Not in any obvious distress, good body built and well hydrated. No pallor, finger clubbing, splinter hemorrhages, jaundice, cyanosis, lymphadenopathy, or peripheral edema.

              Cardiovascular/Peripheral Vascular: Nondistended neck veins (JVP less than 4cm above sternal angle), right carotid pulse 3+ with a thrill and bruit, left carotid pulse 2+ with no thrill or bruit, right and left brachial and radial arteries pulses 2+ with no thrills, right and left femoral arteries pulses 2+ with no thrills and bruits, right and left popliteal arteries pulses 1+ with no thrills, right and left tibial and dorsalis pedis pulses 1+ with no thrills, no renal, iliac and abdominal aorta bruits, and capillary refill is less than 3 seconds in all the digits. Precordium is brisk and tapping. The point of maximal impulse is displaced laterally and less than 3 cm, with a heave but no thrill. S1, S2, and S3 were heard with gallops, no murmurs.

Respiratory: Symmetric chest, moves with respiration with no obvious scars or masses on inspection. the trachea is central, with equal chest expansion, no tenderness or palpable masses, and equal tactile fremitus on palpation. Resonant on percussion. Good air entry and vesicular breath sounds in all lung zones, and no wheezes or rhonchi on auscultation.

Gastrointestinal: Nondistended, moves with respiration, symmetric, normal contour and fullness, umbilicus everted and no visible distended veins, striae, or scars. No tenderness or palpable masses on light and deep palpation. The liver is palpable 2 cm below the right costal margin. Liver span 8 cm. Spleen and both kidneys are impalpable. Tympanic on percussion, no shifting dullness or fluid thrill. No friction rubs over the liver and spleen.

Musculoskeletal: Normal muscle bulk, power of 5/5 in all muscle groups, normal reflexes, and range of movement across all joints.

Neurological: GCS 15/15, oriented to time place, and person, all cranial nerves and sensation intact, no neurological deficits noted, good bladder and bowel function.

Skin: No rashes, darkening, tenting, or nail changes.

Diagnostic Test/Labs: An EKG was done which revealed a sinus rhythm with no ST changes. Other critical tests include cardiac biomarkers particularly, troponin T/I, CK-MB, and myoglobin to exclude myocardial injury (Harskamp et al., 2019). Lipid profile and random blood sugar are required to check the level of lipid control and exclude diabetes mellitus respectively. Additionally, LDH to assess for cell necrosis, BNP to exclude concurrent heart failure, and inflammatory markers especially CRP for prognostication. Similarly, complete blood count with differential, urea creatinine, and electrolytes as well as liver function tests are required as a baseline for medication. Imaging tests include a transthoracic echocardiogram to assess left ventricular function, detect any wall motion abnormalities and identify any complications (Harskamp et al., 2019). Finally, a cardiac CT with IV contrast may be required to rule out differentials such as pulmonary embolism and aortic dissection.

 ASSESSMENT:

Mr. J.M. is a 38-year-old African American male, known patient with hyperlipidemia and hypertension who presents with complaints of sporadic centrally located chest pain that radiates to the left arm. The pain is usually aggravated by exertion but relieved by rest with a history of physical inactivity. On examination, the right carotid artery pulse is increased with a bruit and thrill, the apex is displaced laterally, and S1, S2, and S3 are heard with gallops but no murmurs.

Main Diagnosis- The primary diagnosis is stable angina. Mr. J.M. presents with retrosternal chest pain that is tight and uncomfortable and that radiates to the left arm. This is characteristic of angina. However, these symptoms are worsened by exertion but relieved by rest which is a distinct feature of stable angina (Rousan & Thadani, 2019). According to Rousan and Thadani (2019), atherosclerosis is the most common etiology of this condition. Mr. J.M. has classic risk factors for atherosclerosis including arterial hypertension, hyperlipidemia, alcohol consumption, and overweight as well as a family history of cardiovascular events.

Differential diagnosis

Non-ST segmented elevated myocardial infarction- Myocardial infarction refers to an acute myocardial injury caused ischemia that results in tissue necrosis. This condition also presents with a retrosternal chest pain that dull and tight, precipitated by exertion and radiates to the left arm, shoulder, neck or jaw. Myocardial infarction may also be precipitated by an atherosclerotic event. However, lack of ST changes on EKG suggests NSTEMI (Cohen & Visveswaran, 2020).

Hypertension and hyperlipidemia- Mr. J.M. has previous history of hypertension on metoprolol and hyperlipidemia on Lipitor. Furthermore, lateral displacement of the apex beat as well as a heave suggest left ventricular hypertrophy which is usually a consequence of arterial hypertension (Oparil et al., 2018).

References

Cohen, M., & Visveswaran, G. (2020). Defining and managing patients with non-ST-elevation myocardial infarction: Sorting through type 1 vs other types. Clinical Cardiology43(3), 242–250. https://doi.org/10.1002/clc.23308

Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W. A. M., & van Weert, H. C. P. M. (2019). Chest pain in general practice: a systematic review of prediction rules. BMJ Open9(2), e027081. https://doi.org/10.1136/bmjopen-2018-027081

Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018). Hypertension. Nature Reviews. Disease Primers4(1), 18014. https://doi.org/10.1038/nrdp.2018.14

Rousan, T. A., & Thadani, U. (2019). Stable angina medical therapy management guidelines: A critical review of guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence. European Cardiology14(1), 18–22. https://doi.org/10.15420/ecr.2018.26.1

SUBJECTIVE DATA:

Chief Complaint (CC): ‘I have been experiencing troubling chest pains for the last one month.’

 

History of Present Illness (HPI): Brian Foster is a 58-year-old patient that came to the clinic with complains of experiencing troubling chest pains over the past one month. The patient reports that the chest pains last few minutes. Initially, he thought the chest pain was due to heartburns but have been worsening in nature. He describes the chest pain to be tight and unconformable located in the middle of the chest. Brian denies radiating, arm, crushing, or burning chest pain. He has experienced three episodes over the last month, which last for a few minutes. The patient currently reports no pain (0/10). The patient rated pain severity at its worst at 5/10 According to him, laying down with brief rest alleviate the chest pain. The onset of the chest pain was when he engaged in physical activity while doing yard work. The second episode was while taking stairs t work. His medications are current.

Medications: Brian is currently using the following medications:

Metoprolol 100 mg one po 1 day

Atorvastatin 20 mg po 1 day

Omega-3 fish oils 1200 mg on po q day last dose Thursday 8 am

Tylenol or Motrin when having a headache

Allergies: Brian reports that he is allergic to codeine, which causes nausea and vomiting when he uses it.

 

Past Medical History (PMH):the patient has hypertension and hyperlipidemia, which were diagnosed a year ago. He denies any history of surgeries.

 

Past Surgical History (PSH): Include dates, indications, and types of operations.

The patient denes any history of surgeries.

Sexual/Reproductive History: Non contributory

 

Personal/Social History: Brian denies any history of illicit drug use or tobacco use. He drinks 2-3 alcoholic beverages per week. He only drinks during the weekends. He denies stress. He does not engage in regular exercises, with the last time being two years ago. His diet comprises granola bars, turkey subs and grilled meat and vegetables. He is unsure of his salt intake amount. He drinks four glasses of water a day. He drinks two cups of coffee a day. He does not frequently monitor his blood pressure at home.

Immunization History: His influenza vaccination record is up to date. TDAP was given last 10/2014.

Significant Family History: Include history of parents, Grandparents, siblings, and children.

Brian’s deceased father was hypertensive with hyperlipidemia, obesity and colon cancer. His mother has type 2 diabetes mellitus and hypertension at 80years. His sister aged 52 has type 2 diabetes mellitus and hypertension. His maternal grandfather died at 54 years due to heart attack while maternal grandmother died of cancer at the age of 65 years. His paternal grandmother died of pneumonia at 78 years while his daughter has asthma at the age of 19 years.

Review of Systems

General: the patient denies any fatigue, increased sweating, fever, chills, weight loss, or recent illness.

                Cardiovascular/Peripheral Vascular:He denies palpitations, angina, edema, circulation problems, blood clots, murmurs, or cyanosis,

                Respiratory: The patient denies sore throat, difficult in swallowing, cough, difficulty in breathing, shortness of breath, or shortness of breath.

Integumentary: The patient denies rashes, lesions or skin changes

OBJECTIVE DATA:

Physical Exam:

Vital signs:BP 146/88 mm Hg, MAP 109 mmhG, HR 104 bpm, RR 19, O2 saturation 98% room air, Temperature 36.7C (98F)

General: The patient is well groomed with no visible abnormal findings. He is alert, oriented, with clear speech and in no acute distress.

Cardiovascular/Peripheral Vascular: Jugular venous assessment shows its height of venous pressure to be less than 4 cm above the sternal angle. The chest is symmetrical with no visible abnormal findings. Presence of S1, S2, and S3 heart sounds on auscultation. There is also audible gallop. Absence of abdominal and lower extremity arteries bruit. Presence of a thrill and increased amplitude on palpating right carotid artery. The PMI is displaced laterally with brisk and tapping amplitude. Absence of thrill and abnormal amplitudes in brachial arteries. There are no thrills in popliteal, tibial, and dorsalis pedis arteries except diminished amplitudes. EKG reveals regular sinus rhythm with no ST elevation.

Respiratory: Patient breaths quietly, unlabored with clear breath sounds present in all the lung areas. Adventitious sounds heard to the lower posterior right and fine crackles and rales in the left posterior bases.

Gastrointestinal:The abdomen is symmetrical with no rash, distention, or bruising. Absence of bruits in abdominal aorta. Bowel sounds are normoactive. The abdomen is non-tender on palpation with not palpable mass or organomegaly. There is tympany on spleen, with liver span being 6-12 cm.

Neurological:Alert and oriented, follows commands, and moves all the extremities

Skin:capillary refill of less than 3 seconds, skin is warm, pink, dry, and intact without tenting, edema, and rashes.

Diagnostic Test/Labs:

Several diagnostic investigations are needed to develop an accurate diagnosis for the client. One of them is echocardiogram. An echocardiogram will provide accurate insight into the blood circulation through the heart valves and heart. An exercise stress test may also be essential for this patient. The test will enable the determination of cardiac functioning when the patient engages in his daily routines. A nuclear stress tests may also be needed. The nuclear stress tests will add the benefit of generating images of the ECG recordings while the patient engages in physical activity. A CT scan may also be prescribed. The test will enable the visualization of abnormalities such as the presence of calcification of the arteries. Lastly, cardiac catheterization may be done(Joshi & de Lemos, 2021). This will provide direct visualization of the blood vessels and presence of any blockages.

ASSESSMENT: Stable angina is the client’s primary diagnosis. Stable angina or angina pectoris is a cardiac condition that is characterized by inadequate cardiac tissue perfusion due to occlusion of blood flow. The occlusion impairs blood and oxygen supply to a specific region of the heart muscle, leading to tissue ischemia. Patients with stable angina experience symptoms such as chest pain, fatigue, dizziness, nausea, and shortness of breath when they engage in active physical activities that increase oxygen supply to the cardiac muscles(Ferraro et al., 2020; Joshi & de Lemos, 2021). Brian has symptoms that align with those seen in stable angina. He reports that the symptoms that include chest pain and fatigue develop when he engages in active physical activity. The symptoms also have the same duration and character whenever he experiences them, hence, the diagnosis of stable angina.

One of the differential diagnoses that should be considered in Brian’s case is myocardial infarction. Myocardial infarction occurs when there is complete or partial cessation of blood flow to the coronary artery. This causes damage to the heart muscle. Patients often experience symptoms such as chest pain, nausea, sweating, and chest pain referred to the neck or shoulders(Vogel et al., 2019; Zhang et al., 2022). These characteristics lack in Brian’s case study, hence, myocardial infarction is the least cause. The other differential diagnosis that should be considered in the case study is congestive heart failure. Congestive heart failure is a heart disorder that is characterized by the heart’s inability to pump blood throughout the body organs and tissues.  Patients can suffer from either right-sided or left-sided hear failure. Depending on the type, patients experience symptoms that include weight gain, chest pain, cough, edema, and jugular venous distention(Groenewegen et al., 2020; Palo & Barone, 2020; Slivnick& Lampert, 2019). Brian lacks these symptoms, making it the least likely cause of his health problem.

The other differential diagnosis that should be considered is aortic aneurysm. Aortic aneurysm is a disorder that develops following the weakening of the walls of the aorta. This causes budging and an increased risk of rupture if not treated on time. Patients experience symptoms such as sudden, sharp, crushing chest and back pain, rapid heart rate, and dizziness. The last differential diagnosis is pericarditis. Pericarditis refers to the inflammation of the pericardium due to causes such as infections. Patients experience symptoms such as chest pain and fever, which are not evidence in Brian’s case(Chiabrando et al., 2020). Therefore, additional diagnostic investigations should be undertaken to guide the diagnosis and treatment plan.

 

 

References

Chiabrando, J. G., Bonaventura, A., Vecchi,  é A., Wohlford, G. F., Mauro, A. G., Jordan, J. H., Grizzard, J. D., Montecucco, F., Berrocal, D. H., Brucato, A., Imazio, M., & Abbate, A. (2020). Management of Acute and Recurrent Pericarditis. Journal of the American College of Cardiology, 75(1), 76–92. https://doi.org/10.1016/j.jacc.2019.11.021

Ferraro, R., Latina, J. M., Alfaddagh, A., Michos, E. D., Blaha, M. J., Jones, S. R., Sharma, G., Trost, J. C., Boden, W. E., Weintraub, W. S., Lima, J. A. C., Blumenthal, R. S., Fuster, V., & Arbab, -Zadeh Armin. (2020). Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm. Journal of the American College of Cardiology, 76(19), 2252–2266. https://doi.org/10.1016/j.jacc.2020.08.078

Groenewegen, A., Rutten, F. H., Mosterd, A., & Hoes, A. W. (2020). Epidemiology of heart failure. European Journal of Heart Failure, 22(8), 1342–1356. https://doi.org/10.1002/ejhf.1858

Joshi, P. H., & de Lemos, J. A. (2021). Diagnosis and Management of Stable Angina: A Review. JAMA, 325(17), 1765–1778. https://doi.org/10.1001/jama.2021.1527

Palo, K. E. D., & Barone, N. J. (2020). Hypertension and Heart Failure: Prevention, Targets, and Treatment. Heart Failure Clinics, 16(1), 99–106. https://doi.org/10.1016/j.hfc.2019.09.001

Slivnick, J., & Lampert, B. C. (2019). Hypertension and Heart Failure. Heart Failure Clinics, 15(4), 531–541. https://doi.org/10.1016/j.hfc.2019.06.007

Vogel, B., Claessen, B. E., Arnold, S. V., Chan, D., Cohen, D. J., Giannitsis, E., Gibson, C. M., Goto, S., Katus, H. A., Kerneis, M., Kimura, T., Kunadian, V., Pinto, D. S., Shiomi, H., Spertus, J. A., Steg, P. G., & Mehran, R. (2019). ST-segment elevation myocardial infarction. Nature Reviews Disease Primers, 5(1), Article 1. https://doi.org/10.1038/s41572-019-0090-3

Zhang, Q., Wang, L., Wang, S., Cheng, H., Xu, L., Pei, G., Wang, Y., Fu, C., Jiang, Y., He, C., & Wei, Q. (2022). Signaling pathways and targeted therapy for myocardial infarction. Signal Transduction and Targeted Therapy, 7(1), Article 1. https://doi.org/10.1038/s41392-022-00925-z

Subjective Data Collection: 30 of 30 (100.0%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

  • Found:

    Indicates an item that you found.

  • Available:

    Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint


  • Finding:

    Established chief complaint


  • Finding:

    Reports chest pain

    (Found)

    Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

    Example Question:

    Do you have chest pain?

History of Present Illness


  • Finding:

    Asked about onset of pain


  • Finding:

    Reports chest pain started appearing in the past month

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    When did your chest pain start?

  • Finding:

    Asked about location of pain


  • Finding:

    Reports pain is in center of the chest

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Where is the pain?

  • Finding:

    Reports pain does not radiate

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Does the pain radiate?

  • Finding:

    Denies arm pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Are you experiencing arm pain?

  • Finding:

    Denies shoulder pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Are you experiencing shoulder pain?

  • Finding:

    Denies back pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Are you experiencing back pain?

  • Finding:

    Denies neck pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Are you experiencing neck pain?

  • Finding:

    Asked about duration of pain episodes


  • Finding:

    Reports each pain episode lasted “several” minutes

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    How long does your chest pain last?

  • Finding:

    Asked about frequency of pain


  • Finding:

    Reports 3 pain episodes in past month

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    How many times in the last month have you had chest pain?

  • Finding:

    Reports that pain episodes did not seem related

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Did the episodes seem associated?

  • Finding:

    Asked about severity of pain


  • Finding:

    Reports current pain is 0 out of 10

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    How would you rate your pain on a scale of zero to ten?

  • Finding:

    Reports pain severity at its worst is 5 out of 10

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    How would you rate your pain on a scale of zero to ten?

  • Finding:

    Asked about characteristics of pain


  • Finding:

    Describes pain as tight and uncomfortable

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Can you describe your pain?

  • Finding:

    Denies crushing pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain crushing?

  • Finding:

    Denies gnawing pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain gnawing?

  • Finding:

    Denies burning pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain burning?

  • Finding:

    Asked about aggravating factors


  • Finding:

    Reports pain is aggravated by activity

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    What makes the pain worse?

  • Finding:

    Reports pain occurred with yard work and taking stairs

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    What activity triggered the pain?

  • Finding:

    Reports pain does not worsen with eating

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain worse when you eat?

  • Finding:

    Reports pain does not worsen after spicy foods

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain worse after you eat spicy food?

  • Finding:

    Reports pain does not worsen after high-fat foods

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain worse after you eat high-fat foods?

  • Finding:

    Asked about relieving factors


  • Finding:

    Reports pain relief with brief period of rest

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    What relieves your pain?

  • Finding:

    Denies taking medication to treat chest pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Did you take anything for the chest pain?

Past Medical History


  • Finding:

    Confirmed allergies


  • Finding:

    Confirms allergies

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have new allergies?

  • Finding:

    Asked about related medical conditions


  • Finding:

    Denies angina diagnosis

    (Available)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have a history of angina?

  • Finding:

    Reports high blood pressure

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have high blood pressure?

  • Finding:

    Reports high cholesterol

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have high cholesterol?

  • Finding:

    Denies coronary artery disease

    (Available)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have coronary artery disease?

  • Finding:

    Denies diabetes

    (Available)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have diabetes?

  • Finding:

    Denies previous treatment for chest pain

    (Available)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Have you had previous treatment for chest pain?

  • Finding:

    Asked about blood pressure monitoring


  • Finding:

    Does not frequently monitor BP at home

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    How often do you measure your blood pressure?

  • Finding:

    Reports infrequent BP checks

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    When do you measure your blood pressure?

  • Finding:

    Denies knowledge of typical BP reading

    (Available)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    What is your typical blood pressure reading?

  • Finding:

    Asked about past cardiac tests


  • Finding:

    Reports recent EKG test

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Have you recently had an EKG?

  • Finding:

    Reports annual stress test

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Have you recently had a stress test?

  • Finding:

    Followed up on results of cardiac tests


  • Finding:

    Reports belief that EKG was normal

    (Available)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    What were the results of your last EKG?

  • Finding:

    Reports belief that stress test was normal

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    What were the results of your last stress test?

Home Medications


  • Finding:

    Asked about home medications


  • Finding:

    Reports taking high blood pressure medication

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take medication for high blood pressure?

  • Finding:

    Reports taking high cholesterol medication

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take medication for high cholesterol?

  • Finding:

    Reports occasional ibuprofen use

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take over the counter medications?

  • Finding:

    Reports taking fish oil

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take any supplements?

  • Finding:

    Denies aspirin regimen

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take aspirin?

  • Finding:

    Followed up on high blood pressure medication


  • Finding:

    Reports taking lisinopril

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What medication do you take for high blood pressure?

  • Finding:

    Reports lisinopril dose is 20 mg

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What dose of medication do you take for high blood pressure?

  • Finding:

    Reports taking lisinopril once daily

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    How frequently do you take medication for high blood pressure?

  • Finding:

    Followed up on high cholesterol medication


  • Finding:

    Reports taking atorvastatin

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What medication do you take for high cholesterol?

  • Finding:

    Reports atorvastatin dose is 20 mg

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What dose of medication do you take for high cholesterol?

  • Finding:

    Reports taking atorvastatin once daily

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    How frequently do you take medication for high cholesterol?

  • Finding:

    Reports taking atorvastatin at bedtime

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What time of day do you take your high cholesterol medication?

  • Finding:

    Reports having taken atorvastatin for one year

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    How long have you taken cholesterol medication?

Social Determinants of Health


  • Finding:

    Asked about access to healthcare


  • Finding:

    Reports a primary care provider

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Do you have a primary care provider?

  • Finding:

    Reports last visit 3 months ago

    (Found)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    When was your last visit to a healthcare provider?

  • Finding:

    Reports usually sees healthcare provider every 6 months

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    How often do you see a healthcare provider?

  • Finding:

    Denies transportation is a barrier to healthcare

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Do you have difficulty accessing healthcare because of transportation?

  • Finding:

    Denies finances are a barrier to healthcare

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Do you have trouble affording healthcare?

Social History


  • Finding:

    Asked about stress


  • Finding:

    Reports generally low stress lifestyle

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    What is your stress level?

  • Finding:

    Asked about exercise


  • Finding:

    Denies regular exercise routine

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    What kind of exercise do you get?

  • Finding:

    Reports last regular exercising was 2 years ago

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    When did you last exercise regularly?

  • Finding:

    Asked about typical diet


  • Finding:

    Reports typical breakfast is granola bar and instant breakfast shake

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    What is a typical breakfast for you?

  • Finding:

    Reports typical lunch is turkey sub

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    What is a typical lunch for you?

  • Finding:

    Reports typical dinner is grilled meat and vegetables

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    What is a typical dinner for you?

  • Finding:

    Denies moderation of salt intake

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you moderate your salt intake?

  • Finding:

    Asked about fluid intake


  • Finding:

    Reports drinking 4 glasses of water daily

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you drink water every day?

  • Finding:

    Reports drinking 2 cups of coffee daily

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    How much coffee do you drink per day?

  • Finding:

    Denies soda drinking

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    How much soda do you drink per day?

  • Finding:

    Asked about substance use


  • Finding:

    Denies current illicit drug use

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you use illicit drugs?

  • Finding:

    Denies tobacco use

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you use tobacco?

  • Finding:

    Reports moderate alcohol consumption

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you consume alcohol?

  • Finding:

    Followed up on alcohol consumption


  • Finding:

    Reports drinking 2-3 alcoholic drinks per week

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you drink alcohol?

  • Finding:

    Reports 2-3 drinks in one sitting

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    How many alcoholic drinks do you have in one sitting?

  • Finding:

    Reports drinking only on weekends

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    When do you drink alcohol?

Review of Systems


  • Finding:

    Asked about constitutional health


  • Finding:

    Denies fever

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a fever?

  • Finding:

    Denies chills

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have chills?

  • Finding:

    Denies fatigue

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you feel tired?

  • Finding:

    Denies night sweats

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have night sweats?

  • Finding:

    Denies weight loss

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you experienced recent weight loss?

  • Finding:

    Denies dizziness or lightheadedness

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have dizziness?

  • Finding:

    Denies palpitations

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have palpitations?

  • Finding:

    Asked review of systems for cardiovascular


  • Finding:

    Denies history of angina

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a history of angina?

  • Finding:

    Denies edema

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have any swelling?

  • Finding:

    Denies circulation problems

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have any problems with circulation?

  • Finding:

    Denies blood clots

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you ever had a blood clot?

  • Finding:

    Denies history of rheumatic fever

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a history of rheumatic fever?

  • Finding:

    Denies history of heart murmur

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a history of heart murmur?

  • Finding:

    Denies easy bleeding

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you noticed any unusual bleeding?

  • Finding:

    Denies easy bruising

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you noticed any unusual bruising?

  • Finding:

    Denies blue skin

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Has your skin ever turned blue?

  • Finding:

    Asked about review of systems for respiratory


  • Finding:

    Denies cough

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a cough?

  • Finding:

    Denies difficulty breathing

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you had difficulty breathing?

  • Finding:

    Denies shortness of breath at rest

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have difficulty breathing when lying down?

  • Finding:

    Asked about review of systems for HEENT


  • Finding:

    Denies change in sense of taste

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you experienced a change in taste?

  • Finding:

    Denies sore throat

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a sore throat?

  • Finding:

    Denies difficulty swallowing

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have dysphagia?

  • Finding:

    Asked about review of systems for gastrointestinal


  • Finding:

    Denies nausea

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have nausea?

  • Finding:

    Denies vomiting

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you vomited recently?

  • Finding:

    Denies diarrhea

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have diarrhea?

  • Finding:

    Denies constipation

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have constipation?

  • Finding:

    Denies gassiness

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you been gassy?

  • Finding:

    Denies bloating

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have bloating?

  • Finding:

    Denies heartburn or GERD

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have heartburn or GERD?

Family Medical History


  • Finding:

    Asked about relevant family history


  • Finding:

    Reports family history of heart attack

    (Available)

    Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

    Example Question:

    Has anyone in your family had a heart attack?

  • Finding:

    Denies family history of stroke

    (Found)

    Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

    Example Question:

    Do you have a family history of stroke?

  • Finding:

    Denies family history of pulmonary embolism

NURS 6512 Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

Patient particulars

Initials: G.G

Age: 48years

Sex: male

Race: American

Subjective Data

Chief complaint: I cannot feel my toes on the left foot. I have a tingling sensation in my right heel.

History of presenting illness: G.G is a 48years old male presenting with an inability to feel his toes on the left foot and a tingling sensation on the right foot. These symptoms are of gradual onset over four months. These symptoms proceed with pain in the feet that was sharp and aching. The pain increases in intensity on walking, touch, and cold season. The pain does not radiate, is worse at night, and resting relieves the pain. Other associating symptoms are the weakness of the limbs, burning sensation, muscle spasms of the lower limbs, and reports of loss of memory. The patient denies joint pain and stiffness.

Current medication:

  1. metformin 850MG PO BD for diabetes mellitus,
  2. Tylenol 1g PO PRN for pain and
  3. HCTZ 50mg PO for hypertension

Allergies: the patient denies food and drug allergies

Past medical history: the patient has diabetes mellitus and hypertension. However, he does not go for regular

NURS 6512 Assignment 1 Case Study Assignment Assessing Neurological Symptoms
NURS 6512 Assignment 1 Case Study Assignment Assessing Neurological Symptoms

checks in the hospital. He is not compliant with his treatment. He denies hospital admission, blood transfusion, and surgical procedure.

Social history: the patient is married and has two children. He works as a call center manager. He enjoys reading novels. He takes alcohol every day and smokes tobacco. He takes fast food and does not engage in physical exercise. He does not use his phone while driving. He uses a safety belt while driving and has smoke detectors in his house.

Family history: he is the last born in a family of three. His father passed on at the age of 60years old due to a heart attack. His 70years old mother is obese and has coronary heart disease and osteoarthritis. His elder brother has hypertension and diabetes mellitus. His sister had her left limb amputated up to the ankle joint due to a diabetic foot. His grandparents passed on due to old age. He denies a family history of cancer and psychiatric diseases.

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Review Of Systems

General: the patient denies fatigue, malaise, fever, and weight loss.

HEENT: The patient denies headache, throat pain, nasal discharge, loss of hearing, visual loss, and blurring of vision.

Respiratory system: the patient denies coughing, running nose, wheezing, sputum production, chest pain, tachypnea, and shortness of breath.

Cardiovascular system: the patient denies chest pain, syncope, dyspnea, and orthopnea.

Gastrointestinal system: the patient denies abdominal pain, diarrhea, vomiting, heartburn, and reflux.

Genitourinary system: the patient denies dysuria, hematuria, urgency, and incontinence.

Neurological system:  the patient presents with paralysis, ataxia, numbness, and tingling in the extremities. However, he denies change in bowel or bladder control.

Musculoskeletal system: the patient denies back pain, joint pain, or stiffness.

Hematologic system: the patient denies anemia, bleeding tendencies, or bruising.

Lymphatic system: the patient denies enlarged nodes and spleen enlargement.

Psychiatric:  the patient denies depression, insomnia, anxiety, and hallucinations.

Endocrine system: the patient denies sweating, heat intolerance, polyuria, and polydipsia.

Allergies: the patient denies asthma, hives, eczema, and rhinitis.

Objective Data

Physical examination: the patient is alert and oriented. He has cold and clammy hands and feet. However, he has no pallor, jaundice, cyanosis, edema, or dehydration.

Vitals: blood pressure is at 178/89mmHg, PR 88beats per minute, RR 16 cycles per minute, height 161 cm, weight 110kg, BMI 42.44kg/m2.

Neurological examination: the patient assumes an upright gait and posture. However, he has tremors in the fingers. He cannot perceive pinpricks and gross light touch. He has diminished tendon reflexes. However, the cranial nerves are intact.

Skin: the patient has dry and crusty skin. The skin folds have wrinkles and dark sports. There are erythematous and tender lesions around the joints.

Musculoskeletal system: the patient has muscle wasting on the upper and lower limbs. The bulk, tone, and power are reduced. However, there is no bone deformity or joint swelling.

Cardiovascular system: the heartbeat is at the 5th ICS MCL with S1 and S2. There are no murmurs, rubs, or JVD. The peripheral pulse is present at a regular rate and rhythm. The capillary refill is less than 3sec in all four extremities.

Respiratory system: the chest wall is symmetrical with no scars or mass. The breathing is quiet and unlabored. There is a resonant percussion note over the chest. The breath sounds are clear to auscultation in the upper and lower lobes. There are no rhonchi, stridor, or crackles.

Gastrointestinal system: the abdomen is soft, round, and non-tender with normal-active bowel sounds in all the four quadrants. There are no abdominal bruits and tenderness to light and deep palpation. The liver span is 1cm below the costal margin. There is a tympanic percussion note throughout. The spleen and bilateral kidneys are not palpable.

Diagnostic Tests

  1. Lipid profile to rule out hyperlipidemia
  2. HbA1c and fasting blood sugar to check the blood glucose control
  3. Liver function tests
  4. Erythrocyte sedimentation rate to rule out autoimmune reactions
  5. Thyroid function test to rule out hyperthyroidism
  6. Nerve conduction study findings
  7. MRI plexus to rule out tumors

Assessment

The patient presents with numbness and tingling of the lower limb. Other associating symptoms are pain, muscle spasms, weakness of the limbs, and burning sensation. He has hypertension and diabetes mellitus and does not comply with medication. He leads a sedentary lifestyle, takes alcohol, and smokes tobacco. On examination, he has reduced muscle tone, bulk, power, and reflexes. The skin is cold and clammy with wrinkles and dark spots. Therefore, my differential diagnoses are diabetic neuropathy, transient ischemic attack, and alcoholic neuropathy.

Differential Diagnoses

  1. Diabetic neuropathy
  2. Transient ischemic attack
  3. Alcoholic neuropathy

Diabetic neuropathy is a complication of diabetes mellitus common in patients above 40years old. The complication is a result of poor drug compliance and inadequate treatment. The patient presents with numbness, tingling sensation, muscle cramping, dryness of the skin, loss of sensation of skin pricks, absent tendon reflex, and painful paresthesia (Zakin, et al, 2019). In diabetes mellitus, the patient has reduced absorption of the complex vitamins due to their autonomic effects on the gastrointestinal system. This contributes to the numbness of extremities. Additionally, poor glycemic control causes damage to the nerves hence the patient loses sensation and causes muscle weakness and spasms. This is the actual diagnosis because the patient has diabetes mellitus and does not comply with treatment.

The transient ischemic attack is a neurological dysfunction caused by the brain and the spinal cord without infarction. It causes changes in behavior, memory, gait, speech, and movement. The risk factors are previous surgery, seizure, illicit drugs, metabolic diseases, and cardiovascular diseases (Amarenco, P. 2020). The presenting signs and symptoms are a reduced level of consciousness, muscle weakness, numbness, tingling sensation, loss of memory, and staggering gait. This patient has diabetes mellitus and similar symptoms of a stroke. Finger glucose test for hypoglycemia, cardiac enzymes, and head CT scan will help rule out TIA.

The toxic effects of alcohol cause damage to the autonomic and peripheral nerves. The autonomic effects on the gastrointestinal system cause mal-absorption of the complex vitamins (Sadowski, A., & Houck, R. C. 2018). This leads to thiamine deficiency that eventually induces neuropathy. The presenting signs and symptoms are weakness and muscle wasting, gait dysfunction, tremors, hypothermia, orthostatic hypotension, and paresthesia. However, it is not the actual diagnosis because the patient has no hypothermia, orthostatic hypotension, gait dysfunction, and tremors.

References

Amarenco, P. (2020). Transient ischemic attack. New England Journal of Medicine382(20), 1933-1941. DOI: 10.1056/NEJMcp1908837

Sadowski, A., & Houck, R. C. (2018). Alcoholic neuropathy.  PMID: 29763031

Zakin, E., Abrams, R., & Simpson, D. M. (2019, October). Diabetic neuropathy. In Seminars in neurology (Vol. 39, No. 05, pp. 560-569). Thieme Medical Publishers. DOI: 10.1055/s-0039-1688978

Patient Information:

A.Y, 20 year-old African American male

S.

CC “I have been experiencing intermittent headaches that diffuse all over the head with greatest intensity and pressure above the eyes.”

HPI: The patient came with complaints of intermittent headaches for the last one week. The headaches diffuse all over the head with greatest intensity and pressure above the eyes and spreads through the nose, cheekbones, and jaw. The client reports that analgesics such as acetaminophen provide him with relieve that is not long lasting. The associated symptoms include nausea and photophobia. The severity of pain as reported by the patient was 8/10.

Current Medications: The patient has been using acetaminophen 1 gm TDS for the last four days.

Allergies: The client denied any food, drug, or environmental allergy.

PMHx: The client’s immunization history is up to date.

Soc Hx: The client is a college student undertaking a degree in information technology. He does not smoke or take alcohol. He engages in active physical activity, as he is a member of the university basketball team. His social support comprises of his family members and friends.

Fam Hx: The client denied any chronic illnesses in the family.

ROS:

GENERAL:  The patient appeared well-groomed for the occasion without any signs of malaise or weight loss. He denied fever and chills.

HEENT:  Eyes: The client denied visual loss, blurred vision, double vision or yellow sclerae. He reported photophobia during the episodes of intermittent headaches.

Ears, Nose, Throat:  He denied hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  He denied rash, scars, or itching.

CARDIOVASCULAR:  He denied chest pain, chest pressure, chest discomfort, palpitations or edema.

RESPIRATORY:  He denied shortness of breath, difficulty in breathing, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, vomiting or diarrhea. He also denied abdominal pain or blood. He reported nausea during episodes of intermittent headaches.

GENITOURINARY:  He denied burning on urination, increased urinary frequency, or changes in smell and color of urine.

NEUROLOGICAL:  The patient reports intermittent headaches, denies syncope, dizziness, paralysis, numbness, and tingling of the extremities. He also denied changes in bladder and bwel control.

MUSCULOSKELETAL:  The patient denied muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  He denied anemia, bleeding or bruising.

LYMPHATICS:  He denied enlarged nodes with absence of a history of splenectomy.

PSYCHIATRIC:  He denied history of depression or anxiety.

ENDOCRINOLOGIC:  He denied history of sweating, cold or heat intolerance. He also denied polyuria or polydipsia.

ALLERGIES:  He denied history of asthma, hives, eczema or rhinitis.

O.

Physical exam:

General: The patient appears well groomed, with lack of evidence of weight loss and fatigue

Vitals: Temp 36.7, BP 122/76 P-80, RR 20, SPO2 96,

Head: normocephalic, with no lesions, evidence of trauma, with symmetric facial features. The maxillary and frontal sinuses are tender on palpation.

Ears: The ears are symmetric with absence of ear drainage, loss of balance, and grey tympanic membranes

Eyes: the eyes are symmetric, without jaundice and bleeding. Normal visual acuity

Nose: Absence of nasal flaring, discharge, and septum deviation

Throat: Absence of tonsillitis

Neck: symmetric trachea noted with absence of neck rigidity, swelling, and gross abnormalities of the thyroid

Cardiovascular: presence of S1 and S2, with absence of peripheral edema and advantageous sounds

Gastrointestinal: Absence of abdominal swelling, scars, with normal bowel movements.

Respiratory: Lung sounds clear with absence of advantageous sounds

Neurological: Client is oriented to self, place, time, and events. Pupil reactive to light and equal in size with equal grip in both hands and symmetrical facial features. The self-reported headache is rated at 8/10. There is the presence of intermittent headache, photophobia, and nausea.

Diagnostic results: One of the recommended diagnostic investigations that should be performed for the client is nasal scrapping. Nasal scraping should be performed to obtain a sample for test for esinophils. Radiological investigations are also recommended in case of severe symptoms. The investigations include a head CT scan to detect any abnormalities such as tissue involvement, inflammation of the meninges, and tumors. A MRI may also be done to determine the presence of any abnormality in the brain tissue and soft tissue pathology. Bacterial sinusitis may also be diagnosed by performing sinus aspiration (Iskandar & Triayudi, 2020).

A.

Differential Diagnoses

Sinusitis: The first differential diagnosis for the client in this case study is sinusitis. Sinusitis is a condition characterized by the inflammation of the nasal cavities. The symptoms often last for a period of less than a month. Patients with sinusitis experience symptoms that include frontal headaches with feelings of fullness. Patients also experience other accompanying symptoms that include nausea, vomiting, photophobia, and nasal drainage. The physical assessment findings may reveal tenderness of the sinuses (Iskandar & Triayudi, 2020). The patient in the case study has symptoms that align with this diagnosis, hence, it being the primary diagnosis.

Migraine headache: migraine headache is the secondary diagnosis for the patient in this case study. Patients with migraine headache experience severe, throbbing headache. The accompanying symptoms include photophobia, phonophobia, nausea, and vomiting (Ha & Gonzalez, 2019). This is however a least diagnosis because of the patient experiencing feelings of fullness and involvement of the sinuses.

Allergic rhinitis: The other possible diagnosis for the client is allergic rhinitis. Patients with allergic rhinitis experience symptoms that include headaches, nasal drainage, coughing, sneezing, and pressure on the cheeks and nose (Scadding et al., 2017). Allergic rhinitis is however the least likely diagnosis due to the absence of a history of allergic reaction by the client.

Facial pain syndrome: Facial pain syndrome is the other potential diagnosis for the client in the case study. Facial pain syndrome is attributed to pain affecting the trigeminal nerve. The symptoms associated with it include pain on touching the face, speaking, chewing or brushing teeth (Benoliel & Gaul, 2017). Facial pain syndrome is however the least likely diagnosis due to the absence of pain upon stimulation of the facial muscles.

Acute bacterial pharyngitis: Acute bacterial pharyngitis is the last potential diagnosis for the client. Acute bacterial pharyngitis is attributed to step bacterial infection. Patients experience symptoms that include difficulty in swallowing, headache, chills, and malaise. The patient however does not experience difficulty in swallowing, fever, and chills, hence, acute bacterial pharyngitis not being the primary differential (Harberger & Graber, 2021).

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Benoliel, R., & Gaul, C. (2017). Persistent idiopathic facial pain. Cephalalgia, 37(7), 680–691. https://doi.org/10.1177/0333102417706349

Ha, H., & Gonzalez, A. (2019). Migraine Headache Prophylaxis. American Family Physician, 99(1), 17–24.

Harberger, S., & Graber, M. (2021). Bacterial Pharyngitis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK559007/

Iskandar, A., & Triayudi, A. (2020). Early Diagnosis of Sinusitis Using Expert System Methods: Early Diagnosis of Sinusitis Using Expert System Methods. Jurnal Mantik, 4(2), 1231–1236. https://doi.org/10.35335/mantik.Vol4.2020.927.pp1231-1236

Scadding, G. K., Kariyawasam, H. H., Scadding, G., Mirakian, R., Buckley, R. J., Dixon, T., Durham, S. R., Farooque, S., Jones, N., Leech, S., Nasser, S. M., Powell, R., Roberts, G., Rotiroti, G., Simpson, A., Smith, H., & Clark, A. T. (2017). BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007). Clinical & Experimental Allergy, 47(7), 856–889. https://doi.org/10.1111/cea.12953

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