NR 603 Week 3 Case Study Discussion: Cardiovascular Course: Chamberlain College of Nursing Part One: Initial Patient Evaluation

Patient Overview:

• Name: Sean M.
• Age: 52 years old
• Ethnicity: White male
• Medical History: History of hypertension (HTN), previously taken off HTN medications at the last visit almost 3 months ago.
• Chief Complaint: Sean presents to the clinic following an episode of chest pain three days ago.

Discussion Questions Part One:

1. What further questions do you have for Sean at this visit?

To gather more information for a comprehensive assessment, I would ask Sean the following questions:

• Chest Pain and Associated Symptoms:
  • Can you describe the chest pain in more detail? Was it sharp, dull, or pressure-like?
  • Did the chest pain radiate to your arms, back, neck, or jaw?
  • Did you experience any shortness of breath, dizziness, or lightheadedness during the episode?
  • Have you had any similar episodes since then, or at any other time in the past?
• Activity and Triggers:
  • What were you doing when the chest pain occurred? Were you at rest or physically active?
  • Have you noticed any specific activities that seem to trigger the chest pain or shortness of breath?
• Current Health and Lifestyle:
  • Have you noticed any changes in your energy levels or increased fatigue recently?
  • Have you resumed your workout routine since the episode? If so, how did you feel?
  • Do you monitor your blood pressure regularly? If yes, what have your recent readings been?
• Past Medical History and Risk Factors:
  • Have you ever experienced similar symptoms in the past, even if they were milder?
  • Have you ever been diagnosed with any other heart-related conditions?
  • Do you have any history of high cholesterol, diabetes, or other conditions that might affect your heart health?
• Family History:
  • You mentioned your brother died of melanoma at a young age—was there any history of cardiovascular disease in your family besides your father’s lung cancer and your mother’s stroke?
• Review of Systems (ROS):
  • Have you experienced any palpitations or irregular heartbeats recently?
  • Have you noticed any swelling in your legs or feet?
  • Have you had any headaches, and if so, how frequently? What do you do to alleviate them?

2. What is your differential diagnosis list for this visit thus far with rationale?

Based on Sean’s symptoms and medical history, my differential diagnosis list includes:

• Angina Pectoris (I20.9): Sean’s chest pain, especially the heaviness and associated symptoms like shortness of breath, nausea, and sweating, could indicate angina, particularly if it was precipitated by physical activity or stress.
• Myocardial Infarction (MI) (I21.9): The episode of chest pain could be a warning sign of an acute coronary event. The ST depression on the EKG increases the suspicion of myocardial ischemia.
• Gastroesophageal Reflux Disease (GERD) (K21.9): GERD can mimic cardiac chest pain, presenting with a burning sensation, heaviness, and even nausea. Given that the pain was short-lived and hasn’t recurred, this could be a possibility.
• Costochondritis (M94.0): Inflammation of the costal cartilage can cause chest pain, which might be mistaken for cardiac pain. This diagnosis is considered if there is tenderness to palpation along the costosternal junctions.
• Anxiety or Panic Disorder (F41.9): Anxiety can manifest with chest tightness, shortness of breath, sweating, and palpitations. If Sean is under significant stress, this could be a differential to consider.

3. Based on your differential diagnoses list, identify what body systems you’d examine along with pertinent positive/negatives in each system and any diagnostic tests you would like to perform.

Body Systems to Examine:

• Cardiovascular System:
  • Pertinent Positives: Evaluate for any signs of ischemia such as ST changes on EKG, auscultate for murmurs, S3/S4 gallops, and assess peripheral pulses.
  • Pertinent Negatives: Absence of jugular venous distention (JVD), peripheral edema, or heart murmurs.
• Respiratory System:
  • Pertinent Positives: Assess for wheezing, rales, or rhonchi, which could indicate cardiac or pulmonary etiology.
  • Pertinent Negatives: Clear lung fields on auscultation, absence of respiratory distress.
• Gastrointestinal System:
  • Pertinent Positives: Assess for epigastric tenderness, which could indicate GERD or other GI-related causes of chest pain.