Case Study: Mr. J is a 56-year-old male who presented to your office today for complaints of chest pain

Case Study: Mr. J is a 56-year-old male, who presented to your office today for complaints of chest pain.  

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), GERD

Medications: Lisinopril 10mg Once daily, Norvasc 5mg Daily, Lipitor 40mg once daily, Pepcid 20mg BID, Ventolin Inh. PRN Q6hours, Metformin 500mg BID

Surgical 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) HIV

Social HX: Smokes 1PPD of cigarettes, occasional cocaine use, ETOH use (6-9 beers/week)

VS: Temp 97.7 oral, HR 86, BP 155/65, RR 16, SPO2 97% RA HT:5’7”, WT: 260lbs

Physical Exam: This is a 56yo Caucasian male, 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.

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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

Instructions: Reformat the above data as follows from Bates:

You must include a full ROS and Physical Exam for full Credit

1). CC:

HPI

PMH (include surgeries and traumatic injuries)

Current medications

Allergies

Psychosocial

Family History – genogram (you can draw it and place on last page, or create in word document)

ROS – complete information

Physical Exam – complete information

2). List 3 Differential Diagnoses in descending order of suspicion

(Number these as #1, #2, #3, your #1 should be your primary working DX)

3). List the pertinent positives/negatives to support your differentials. (at least 3 of each)

4). List additional history data that would support your primary differential diagnosis and why? (At least 10 history questions listed)

5). List any additional physical components that would support your primary differential diagnosis and why? (At least 5 PE findings that would better help you diagnose your primary differential)

6). Select your primary differential diagnosis as #1 and include 2 other differentials:

a) Give a brief pathophysiologic description of each disorder (< 10 sentences)

b) Etiology (primary dx)

c) Usual clinical findings or features (primary dx)

d) Diagnostic criteria (if any) for making the diagnosis (primary dx)

e) Treatment Plan – include specific treatments like pharmacotherapy (be specific with doses, amounts, etc.) (for your PRIMARY DX)

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