NR 603 Week 3 Case Study Discussion: Sean M. Setting: Large Urban City - Family Practice Clinic Patient: Sean M., 52-year-old white male Chief Complaint (CC): Chest pain three days ago

Part One: Initial Evaluation

Further Questions for Sean at This Visit:

To better understand Sean’s condition and to guide the assessment, I would ask the following questions:

1. Chest Pain Details:
   • Have you experienced this type of discomfort before? If yes, when and under what circumstances?
   • Can you describe the chest pain in more detail? Was it sharp, dull, squeezing, or pressure-like?
   • Did the chest pain radiate to your arms, back, neck, or jaw?
   • Did you experience any other symptoms such as 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?
2. Symptom Triggers and Relief:
   • 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?
   • Did anything relieve the chest pain, such as rest, or taking deep breaths?
3. Current Health and Activity:
   • Have you noticed any changes in your energy levels or increased fatigue recently?
   • How has your physical activity been since the episode? Are you able to perform your regular activities without discomfort?
   • Have you resumed your workout routine since the episode? If so, how did you feel?
4. Medical History and Risk Factors:
   • Have you ever experienced similar symptoms in the past, even if they were milder?
   • Do you regularly monitor your blood pressure at home? If so, what have your recent readings been?
   • Have you been keeping up with your lifestyle changes to manage your elevated cholesterol?
5. Family and Social History:
   • Given your family history of lung cancer and stroke, have you ever had any heart-related evaluations before?
   • Can you tell me more about your alcohol consumption and how often you smoke cigars?
   • Are there any other health concerns or changes you’ve noticed recently?
6. 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?
   • Any recent weight loss or changes in appetite?

Differential Diagnosis List with Rationale:

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

1. Unstable Angina (I20.0): The episode of chest pain, accompanied by shortness of breath, nausea, and sweating, could indicate unstable angina, particularly if it was precipitated by physical activity or stress.
2. Myocardial Infarction (MI) (I21.9): Although the episode was brief, the symptoms could be indicative of an acute coronary event, especially with his history of hypertension and elevated cholesterol.
3. Gastroesophageal Reflux Disease (GERD) (K21.9): GERD can mimic cardiac chest pain, presenting with a burning sensation, heaviness, and even nausea. Given the short duration and non-recurrence of symptoms, this could be a possibility.
4. 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.
5. 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.

Body Systems to Examine and Pertinent Positive/Negatives:

1. Cardiovascular System:
   • Positives: Assess for signs of ischemia (ST changes on EKG), auscultate for murmurs, S3/S4 gallops, and assess peripheral pulses.
   • Negatives: Absence of jugular venous distention (JVD), peripheral edema, or heart murmurs.
2. Respiratory System:
   • Positives: Assess for wheezing, rales, or rhonchi, which could indicate cardiac or pulmonary etiology.
   • Negatives: Clear lung fields on auscultation, absence of respiratory distress.
3. Gastrointestinal System:
   • Positives: Assess for epigastric tenderness, which could indicate GERD or other GI-related causes of chest pain.
   • Negatives: Absence of rebound tenderness or abdominal rigidity.
4. Musculoskeletal System:
   • Positives: Palpate the chest wall for tenderness, which could suggest costochondritis.
   • Negatives: Lack of reproduci