case study History: Mr. J is a 56 year old male, who… case study Hi

case study History: Mr. J is a 56 year old male, who… case study History: Mr. J is a 56 year old male, who presented to your office today for complaints of chest pain. He states that his pain has been occurring intermittently for 3 days. He admits that with any strenuous activity he develops this pain in his chest. When he points to the area where he is describing, it is by his left areola. He states he has been fatigued, and very “winded” with any exertion. He denies any recent travel, and denies any sick contacts at home. He has been vaccinated for COVID with 3 vaccines. He denies any history of PE/DVT. Denies any extremity swelling or pain. He denies cough. He has had poor appetite over the past 3 days. Denies nausea, vomiting or diarrhea. He admits that last evening while sitting on his couch, he has “pins and needles” in his left arm, which went all the way to his fingertips. He smokes 1 pack of cigarettes a day. Has a “chronic cough” he states.  PMHX: HTN, HLD, CAD, DM, COPD (not on home oxygen), GERDMedications: Lisinopril 10mg Once daily, Norvasc 5mg Daily, Lipitor 40mg once daily, Pepcid 20mg BID, Ventolin Inh. PRN Q6hours, Metformin 500mg BIDSurgical HX: CABGX2 (2020)FHX: Mother(87yo) COPD, HTN, CAD, Father (89yo)Deceased d/t MI, Wife (50yo) HTN, COPD, Daughter (30yo) Healthy, Son (32yo) Schizophrenia, Daughter (34yo) HIVSocial HX: Smokes 1PPD of cigarettes, occasional cocaine use, ETOH use (6-9 beers/week) VS: Temp 98.7 oral, HR 99, BP 150/65, RR 16, SPO2 97% RA HT:5’7″, WT: 260lbs Physical Exam: This is a 56yo Caucasian mal, appears states age. Tobacco stained fingernails. A&OX3, Well dressed. Oral mucosa pink, moist, intact. Poor dentition with multiple areas of plaque/dental caries. EOMI, PERRLA 2+ BL, Neck supple, no palpable thyroid. No JVD or cervical lymphadenopathy. Chest wall without pain to palpation, no rashes/lesions noted. Lungs with scattered wheezes/rhonchi that clear with coughing. No egophony, bronchophony, or whispered pectoriloquy. Heart with normal s1/s2, no murmur appreciated to auscultation. 2+ pulses in BL upper and lower extremities. Calves are symmetric, temperature intact BL, with negative homan’s sign BL. 1+ edema in BL lower extremities. ROM intact in all joints. ABD is SNTTP, BS X 4.  Diagnostic Studies: EKG Normal Sinus Rhythm, Hgb 10.5, Plts 250, BUN 25, CREA 0.9, Na 135, K 3.7, Glucose 140, BNP 98         GRADING SHEET FOR NUR 631 HISTORY DATA- 40 points HX pts____Chief Concern (CC) (8) ____Complete History of Present Illness (HPI) (12) ____Pertinent PMH (meds, allergies, social risks) (4) ____Review of Systems (Case data documented appropriately) (12) ____Family History (with genogram) (4) ____ PHYSICAL EXAM – 40 points PE pts_____Case data appropriately documented in FULL PE DIFFERENTIAL DIAGNOSIS – 10 points DD pts____List 3 Differentials to explain primary problem (3@1ea=3) ____Give a brief pathophysiologic description of each DD: (3)Etiology ____Usual clinical findings or features ____Pertinent positives/negatives listed to support primary DD (2) ____List additional history s to support primary DD (1) ____List additional physical findings to support primary DD (1) ____ PLAN OF CARE -5 points Plan pts___(specific treatments including meds – be specific with doses, times)Pharmacologic (2) ____Non Pharmacologic (1) ____Patient Education (1) ____Follow Up (1) ____*Neatness, typed, submitted on time, appropriate format, use of appropriate terminology, references – 5 points Form pts___Total poin Health Science Science Nursing NUR 631 Share EmailCopy link Comments (0)

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