Case Study For Patient With Chest Discomfort Discussion

Case Study For Patient With Chest Discomfort Discussion

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SUBJECTIVE DATA:
Chief Complaint (CC): chest pain

History of Present Illness (HPI): BF is a Caucasian male who is 58 years old and presents with complaints of recurrent chest discomfort that has happened three times in the past month. The patient states that the pain is worse with exertion and that it is relieved by sitting or lying down. The patient reports that each episode lasts a few minutes and the level of discomfort is a 5/10. The patient describes the discomfort as being “tight and uncomfortable” and indicating that it is located in the middle of his chest. Denies having pain that is radiating to the neck, arm, or back. Denies trouble breathing. At this time, the patient denies having any chest pain and rates their discomfort as a 0/10.

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Medications: Case Study For Patient With Chest Discomfort Discussion
Omega-3 Fish Oil 1200mg BID
Atorvastatin 20mg QHS
Lisinopril 20mg daily

Allergies:
Codeine- vomiting, nausea

Past Medical History (PMH):
Hypertension
Hyperlipidemia

Past Surgical History (PSH): None

Sexual/Reproductive History: Heterosexual. Has two adult children.
Monogamous relationship with wife.
Personal/Social History: Reports occasional alcohol use. Denies tobacco or illicit drug use Case Study For Patient With Chest Discomfort Discussion

Immunization History:
COVID-19 2021
Influenza 10/2021.
Tdap 10/2014.

Significant Family History:
Mother –Hypertension, diabetes
Father: -died from colon cancer, history of obesity, hyperlipidemia, and hypertension
Sister- hypertension, diabetes
Maternal grandmother-died from breast cancer.
Maternal grandfather-died from stroke.
Paternal grandmother-died from pneumonia

Review of Systems:

General: Denies fever, fatigue, or weight change.
Cardiovascular/Peripheral Vascular: Reports sporadic sternal chest pain. Denies palpitations or edema
Respiratory: Denies shortness of breath or cough. .
Gastrointestinal: Denies abdominal pain, nausea, vomiting, constipation, or diarrhea.
Musculoskeletal: Denies muscle pain, or pain. Denies history of injuries or fractures.
Psychiatric: Denies history of depression or anxiety
OBJECTIVE DATA: Case Study For Patient With Chest Discomfort Discussion

Physical Exam:
Vital signs: 146/90, P-104, R-19, T-36.7C. Ht. 5’11. Wt 197lbs. BMI 27.5

General: Alert and oriented x 4. Appears well dressed and well-groomed. Clear and coherent speech
Cardiovascular/Peripheral Vascular: S1, S2,S3 noted no murmus or rubs. PMI displaced laterlally at mitral area
Respiratory: Unlabored breathing. Breath sounds clear to auscultation. Fine crackles in posterior bases of lungs.
Gastrointestinal: Round, Soft abdomen, no tenderness. Normoactive bowel sounds. No tenderness to both light and deep palpitation. Tympanic throughout No abdominal bruits.
.
Musculoskeletal: Symmetric. Full ROM.
Neurological: DTR’s intact. Cranial Nerves grossly intact.
Skin: No cyanosis, edema, or rash noted

Diagnostic Test/Labs:
EKG- Normal rate and rhythm. No ST elevation.

ASSESSMENT:
Angina Pectoris (Stable Angina): Because of constricted or blocked arteries, people who regularly engage in strenuous physical activity or experience intense emotions may have chest pain or discomfort known as stable angina. It is often characterized as a painful pressure, fullness, or squeezing sensation in the middle of the chest that is triggered by effort and relieved while resting. This discomfort is generally brought on by physical activity and is relieved when the individual is resting (Gillen & Goyal, 2021)Case Study For Patient With Chest Discomfort Discussion.
Congestive Heart Failure: CHF is the outcome of any condition that hinders the ability of the ventricles to fill with blood or evacuate blood into the systemic circulation (Malike et al, 2021). Patients often complain of feeling tired, having difficulty tolerating activities, retaining fluid, and having difficulty breathing. An S3 gallop, pulsus alternans, edema, jugular venous distention, cardiomegaly, pleural effusion, and tachycardia are some of the cardiac symptoms. An echocardiogram is recommended in order to rule out the possibility of CHF.
Coronary Artery Disease: Plaque that has accumulated in the artery walls is the root cause of this condition, which affects the cardiovascular system. Angina, weakness, and a shallow or rapid breathing are some of the symptoms. A history of cardiovascular disease in one’s family, obesity, inactivity, poor nutrition, and smoking are all considered to be risk factors for the condition (CDC, 2020). Men are more likely to suffer adverse outcomes than women (Shahjehan & Bhutta, 2021). BF is associated with a number of risk factors, such as hyperlipidemia, hypertension, a low physical activity, and advanced age.

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References
Gillen, C., & Goyal, A. (2021). Stable Angina. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK559016/
Malik, A., Brito, D., Vaqar, S., & Chhabra, l. (2021). Congestive heart failure. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK430873/
Shahjehan, R.D., & Bhutta, B.S. (2021). Coronary artery disease. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK564304/ Case Study For Patient With Chest Discomfort Discussion