NR603 Week 3 Case Summary

Running head: WEEK 3: SUMMARY 1 Week 3: Case Presentation Summary Chamberlain University NR603: Advanced Clinical Diagnosis and Practice Across Lifespan March 2018 SOAP Week 3 Patient Information: L.M., 60-year-old male, African American, insurance unknown. (S) Subjective: CC: chest pain three days ago HPI: "My wife made me come, I feel fine." Three days ago, Larry M. felt short of breath, had this heavy feeling in his chest, and he got kind of nauseous and sweaty. It lasted only about 3 minutes, and it has not happened again, but he does feel a little more tired. "It could be that I have not worked out since it happened." Current Medications: None Allergies: NKDA PMHx: Reports general health as good. He Had been feeling great since starting to work out and lost weight. Had lots of energy and felt great until this episode three days ago. Now he is a little concerned because he feels a little more tired when he works out. He has not done as much strenuous running and has not worked out since the episode. Hypertension- lifestyle changes recommended. Elevated cholesterol, lifestyle management was initiated. WEEK 3: SUMMARY 2 PSHx: T and A, cholecystectomy, vasectomy. Childhood Illnesses: chicken pox. Immunization Hx: Refuses flu shot. Other Screenings: Not reported. Soc Hx: Married for 20 years, works as an architect. Enjoys a beer or a glass of whiskey and the occasional cigar when playing poker with his buddies. Fam Hx: Parents are deceased. Father had lung cancer and mother died from complications of a stroke. Brother died at 44 from malignant melanoma. Another sister and brother are healthy. ROS: CONSTITUTIONAL: No reports of fever, chills. Reports planned weight loss. Reports increased fatigue starting 3 days ago. HEENT: None reported. SKIN: None reported. CARDIOVASCULAR: Reports shortness of breath, chest heaviness, nausea and sweating. RESPIRATORY: Shortness of breath 3 days ago, none since. Denies sputum. GASTROINTESTINAL: Nausea 3 days ago. GENITOURINARY: None reported. NEUROLOGICAL: None reported. MUSCULOSKELETAL: None reported. HEMATOLOGIC/LYMPHATICS: None reported. PSYCHIATRIC: None reported. ENDOCRINOLOGIC: None reported. ALLERGIES: None reported. O: Vital signs: B/P 146/90, HR 70, Sao2 97% RA. Height 5’”, weight 220 pounds BMI: 33.5 PHYSICAL EXAM GENERAL: African American male in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present. HEENT: African American male in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. No AV nicking noted. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender. Nose: Nares patent without exudate. Sinuses non-tender to palpation, Right-sided Deviation. Throat: Oropharynx moist, no lesions or exudate. Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Mild JVD in recumbent position WEEK 3: SUMMARY 3 LUNGS: Lungs clear to auscultation bilaterally. Respirations unlabored. No rashes or vesicles noted on chest. HEART: Heart S1 and S2 noted, RRR, no murmurs, noted. No parasternal lifts, heaves, and thrills. Peripheral pulses equally bilaterally. PMI 5th ICS displaced 4cm laterally. No edema in lower extremities. ABDOMEN: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted. Diagnostic results: Labs from 3 months ago: Total Cholesterol: 230 Ldl 180 Hdl 38 In office EKG: ST depression A: PRIMARY PRESUMPTIVE DIAGNOSIS: Old myocardial infarction (I25.2)- NSTE-ACS most commonly presents as a pressure-type chest pain, occurring at rest or with minimal exertion, lasting greater or equal to 10 minutes. Patients also present with diaphoresis, dyspnea, nausea, abdominal pain, or syncope. Unexplained new onset or exertional dyspnea is the most common angina equivalent. Changes in 12-lead ECG include ST depression, transient ST-elevation, or new onset T-wave inversion [Ree16]. This patient is not currently experiencing these symptoms, so this is not an acute NSTEMI. The patient experienced transient chest heaviness 3 days ago with associated nausea and diaphoresis. He becomes more easily fatigued since this episode. His ECG shows ST depression. SECONDARY DIAGNOSIS: 1. Hypertension (I10)-The new American College of Cardiology and American Heart Association guidelines define as normal blood pressure as a reading less than 120/80 mm Hg [Whe17]. Based on the new guidelines this patient has Stage 2 hypertension which is classified by a systolic reading at least 140 or diastolic at least 90 mm Hg [Whe17]. The new guidelines stress the importance of using proper technique to measure blood pressure; recommend use of home blood pressure monitoring using validated devices; and highlight the value of appropriate training of health care providers to reveal "white-coat hypertension. WEEK 3: SUMMARY 4 This patient’s blood pressure is 146/90 at the office visit. No other blood pressures are available at this time; however he has chronic hypertension. 2. Hyperlipidemia (E78.5)- Hyperlipidemia is one of the most common causes for ACS, and is defined by elevated levels of LDL, triglycerides, and total cholesterol (Last, Ference, & Falleroni, 2011). The patient’s last labs showed: Total Cholesterol-230, LDL-180, HDL-38. 3. Tobacco Use (Z72.0)-Smoking remains the leading preventable cause of premature disease and death in the United States. Smoking has been casually linked to disease of nearly all organs of the body; most recently including diabetes mellitus, rheumatoid arthritis and colorectal cancer [Ame161]. The patient has occasional cigars during his poker nights. 4. Obesity (E66.9) – Obesity is defined as a BMI of 30.0 or higher. Obesity is frequently subdivided into categories: Class 1: BMI of 30 to < 35; Class 2: BMI of 35 to < 40; Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity (CDC, 2017). The patient’s BMI is 33.5. He is considered Class 1 obesit