Case StudyChest PainKathleen Cornell, FNP student

SUNYITMarch, 2014

Demographics Patient: JD

Age: 36 years

Gender: Caucasian female

Height: 5’4”

Weight: 201

BMI: 33 (overweight)

Source of encounter: Community Health Clinic. Referral from the emergency department of Saratoga Hospital for follow up diagnosis of Pleurisy

Chief Complaint 36 Year old Caucasian female complaining of chest

pain left pectoral area that radiates down left arm on occasion. Currently, the pain level to the chest is an 8 out of 10, has no relief from pain medication, or rest. The pain does not increase with inspiration or expiration and does not radiate into back, jaw, or right side, nothing makes it worse or better. It is not reproducible with palpation. States she has on occasion a rapid heart beat at rest with shortness of breath, but the shortness of breath is with ambulation. Patient states she was in the emergency room ten days prior to this visit and, “they diagnosed me with pleurisy”.

History of Present Illness

36 Year old Caucasian female presenting for a follow-up visit regarding emergency room diagnosis of Pleurisy.

Ten days prior to this visit, the patient was in the emergency room for complaints of chest pain across her chest for greater than 24 hours, no arm or jaw pain at the time. Patient states the pain is located at left chest wall pectoral area on occasion it will radiate with tingling down her left arm. Currently the pain is an 8 out of 10, and is constant throughout the day. It does not increase or decrease with movement or inspiration/expiration. Not reproducible with palpation to site.

History of Present Illness

States it sometimes gets worse at night when sleeping it will cause her to wake up. States my boyfriend tells me I snore really loud lately. The pain is crushing/stabbing like someone is punching her. She has had no previous history of chest pain.

Gets light headed and short of breath on occasion with walking.

Past Medical History Medications: Chlorathalidone 25 mg QD,

Flexeril 10mg QD

NKDA, allergy to bee sting causes anaphylaxis, no food or latex allergy

Past Surgical History: Gallbladder 03’, Right ankle tendon repair 05’, Tubaligation 05’

Immunizations: Last tetanus 08’, Flu vaccine 13’, not sure of other immunizations

Family History

Three children – two boys, 15, & 9, one girl – 12

One miscarriage, one termination

Parents: Maternal grandmother had CHF, Father deceased 35 years – O.D., Mother alive 56 years alcoholic, low B/P, siblings – one brother 32 yr – well, one sister 33 yr - well

Social History Works at Price Chopper as cashier day shift full

time. Started work two months ago.

Smokes 10 cigarettes a day for 15 years, waiting for patches to arrive will be quitting.

Alcohol once a month socially, no street drugs in the past or current.

Lives with boyfriend in an apartment, has vehicle for transportation, wears a seatbelt while driving and passenger, active with children’s activities with school. Denies physical or emotional abuse.

ROSGeneral: Denies fever, chills, weight loss or appetite change

Skin: Denies excessive sweating, changes in hair or nails

Head: Positive for headaches over last year, saw a physician had negative review. Positive for dizziness with ambulation on occasion.

Neck: Denies lumps, pain on ROM, stiffness, or goiter.

Ears: Denies ringing in ears, hearing loss, pain, use of hearing aids, denies exposure to excessive noise.

Eyes: Denies visual changes, infection, sensitivity to light, does not wear glasses, double vision, glaucoma, or cataracts.

ROS Nose & Sinus: Patient denies change of smell,

nasal obstruction, infections, nose bleeds, hay fever, sinus pain or infection.

Mouth & Throat: Denies hoarseness, dryness, ulcers, bleeding gums, abscess to gum, tonsils or soft tissue, denies taste disturbance. Has all teeth with fillings in back molar region upper and lower.

Respiratory: Denies wheezing, positive cough for several weeks, short of breath with walking on occasion, denies emphysema, asthma.

ROS Cardiac: Positive for chest pain, palpitations

on occasion, denies murmurs, positive for high blood pressure for one year. Denies, previous MI, angina or EKG changes.

Peripheral vascular: Denies leg pain, vericose veins or past leg clots.

Gastrointestinal: Denies appetite loss, positive for heartburn, no vomiting. Denies jaundice, constipation, diarrhea, ulcers, gallstones, or tumors

ROS Urinary: Denies frequency, burning on urination,

urgency, blood in urine. No STD’s, sores, pain to labia/vaginal area.

Musculo Skeletal: Positive for pain down left arm on occasion feels more like tingling and tightness. Denies stiffness to joints, deformity, swelling, full range of motion, back pain, difficulty with ambulation.

Neurological: Denies abnormal thoughts, remote and recent history intact, seizure disorder, paralysis, weakness, fainting, stroke. Positive for occasional tingling/numbness to left arm radiating to fingers.

ROS Hematological: Denies anemia, blood

transfusions, easy bruising.

Endocrine: Denies diabetes, thyroid disease or hormone therapy.

Psychiatric: Denies tension, mood changes, hallucinations, or paranoia. Has a history of anxiety/depression.

OBJECTIVE General Appearance: Well developed, well nourished

36 year old Caucasian female, who is alert, oriented to person, place, and time. Appears anxious with episodes of crying during initial interview.

Vitals: B/P – 177/118 left arm sitting, 152/109 right arm sitting. P – 97, R – 18, O2 sat – 100% on room air, T-98.0, Weight – 201lb, Height – 5’4”, BMI – 33.

Head: Normocephalic, no lesions, scaling, hair distribution even, brown.

Skin: Pale, warm, dry, tattoo to left inner forearm 5cm in length by 3cm wide, injected 2002. Nail beds 160 degree angle, no clubbing, positive blanching 5 seconds. No rashes, turgor taught.

OBJECTIVE Eyes: Symmetrical, pupils 3mm reactive to

consentual, convergence and close, red reflex noted to both eyes. Conjunctiva without swelling, or redness, sclera white without discharge. Eyelids equal in form, EOM tested without extropia, or hyperopia. Last eye exam 2013/11.

Ears: Non tender tragus bi-lateral ears, external ear canal without redness, swelling, or discharge, left ear tympanic membrane at 7o’clock, cone of light visualized, right ear tympanic membrane at 5o’clock, cone of light visualized. Hearing without out deficit both ears tested by Weber and whisper.

OBJECTIVE Nose/Sinus: Nostrils without flaring, symmetrical,

turbinates, pink without drainage, palpation of frontal sinus negative for pain, olfactory nerve functional with smell of coffee grounds identified.

Mouth/Throat: Teeth intact with mercury fillings to molars upper and lower, buccal pink, stenson’s ducts visualized, soft and hard palate without swelling, lesions, no swelling to gums, no deviation to uvula equal with rise, tonsills visualized.

Neck: Lymphatics, left and right preauricular, posterior auricular, occipital, superficial cervical, submandibular non palpable, Thyroid non palpable.

OBJECTIVE Chest/Thorax: Lungs clear on auscultation

AP& Lateral diaphragmatic excursion 5cm, respirations equal chest rise symmetrical, no increase in AP diameter. Does self breast exams most recent breast exam was with yearly pap 01/14

CV/PV: Heart sounds rate regular, rhythm regular, no murmurs, S1 greater than S2. No heaves, thrills,PMI 5th LICS MCL, peripheral pulses 2+, dorsalis pedis 1+, no carotid bruit. Homan’s negative capillary refill immediate.

OBJECTIVE Abdomen: Symmetrical, no scars, lesions, bowel sounds

high pitch over small bowel, tympany, no guarding or pain on palpation, no organomegaly over spleen.

GU: No complaints of pain on urination, frequency, urgency, last menstrual cycle – 2/26/14, normal flow. Last pap exam 01/14, normal.

Musculoskeletal: Ambulates without assistance, full range of motion to upper and lower extremeties, no increased curvature of back, strength 5+ throughout.

Neurological: Speech intact, appropriate for age, oriented to time and place, reflexes 2+ to bicep, tricep, quadricep, achilles. Negative Babinski sign

Differential Diagnosis Nurse Practitioner assessment: R/O

pulmonary embolus

My Assessment: Reflux, obstructive sleep apnea, Hypertension

DIAGNOSTIC TESTS EKG, ECHO

Labs: TSH, A1C, COMP, CBC, VIT. D, LIPID PROFILE, URINALYIS, TROPONIN

PLAN According to the patient’s history of smoking, give smoking

cessation information and teaching.

Review EKG with patient, get an Echocardiogram today have patient return to office to discuss test results.

Review lab work with patient in one week.

Start patient on Ace Inhibitor low dose lisinopril 10mg QD

Norco 2.5mg Q 4-6 hours for pain as needed. 20 tablets dispensed

Review test results from Emergency Department.

Refer patient to Pulmonary for further evaluation of possible Cardiopulmonary insufficiency, sleep apnea.

Epocrates. (2013)

Definitive reason for Diagnosis

Hypertension: diagnosed when systolic B/P is greater than 140mmHg, or diastolic greater than 90mmHg. Blood pressure is usually lower at night and the loss of this dip shows an association with cardiovascular risk.

The medication this patient is taking is classified as a diuretic (Chlorthalidone), I would consider adding a ACE inhibitor and get a baseline BUN/Creatinine level.

Review CT scan from ER – showed no abnormalities, no pulmonary embolism. EKG – showed normal sinus rhythm, ECHO – showed no abnormalities. Blood work showed normal troponin levels, labs within normal limits except Potassium was 3.2.

Papadakis, M., & McPhee, S. (2013).

Reason for Diagnosis Reflux – The feeling of burning radiating to the neck

caused by gastric acid material into the esophagus. One third of patients experience chest pain of unkown origin. 50% have increased amounts of acid, this has shown a correlation between reflux and chest pain when cardiac is ruled out.

Obstructive sleep apnea – most people get mixed sleep, may complain during the day of feeling fatigued, headaches, recent weight gain, anxiety, & hypertension. Smoking and hypothyroid are additional risk factors for sleep apnea.

Papadakis, M., McPhee, S. (2013).

Management Plan Have patient follow medication plan as

discussed earlier.

Review smoking cessation plan with patient.

Discuss how appointment with Pulmonary went.

Discuss lab work, new medication status, and pain management for chest pain, & blood pressure control.

Works Cited Epocrates (2014). Athena health company.

Retrieved from http://www.epocrates.com.

Papadakis, M.A., & McPhee, S. J. (2013). Current medical diagnosis & treatment. (52nd ed.). New York, NY: McGraw-Hill Companies, Inc.