Reference no: EM132469959
Cardiac and Peripheral Vascular Systems
CASE STUDY 1
Chief Complaint
A 55 y.o. male comes to the clinic with complaints of difficulty breathing while running across the street to his office yesterday. He had to stop at the median and loosen his tie and collar so he could catch his breath. He felt a bit lightheaded at the time. He denies chest pain, palpitations, nausea, vomiting, and diaphoresis. He has not had these symptoms in the past. It did not reoccur during the rest of the day, but he felt a similar chest tightness and shortness of breath when he got up this morning, so he decided to come to the office.
Past Medical History
Current Meds
- Sudafed 12 Hour as needed for allergy symptoms
- Flonase I spray BID
Family History
- Mother, age 80, in a nursing home with Alzheimer's; no other health history known
- Father, age 82, alive, fair health, HTN
- Sister, age 53, good health
Psychosocial History
Smoked one pack per day for approximately 35 years; quit 3 years ago. Started exercising 3 years ago when he quit smoking; aerobics for 1 hour 5 days per week. Drinks two glasses of wine daily with dinner, beer on the weekends, approximately three per day. Divorced, lives alone. No children. Works for the governor's office as a programmer.
Review of Systems
- General: Has lost 5 to 10 pounds since he began exercising.
- HEENT: Wears eye glasses, no recent prescription change. Denies visual changes, diplopia, photophobia, infections. Last eye exam 2 months ago. Denies sore throats, frequent colds, hearing difficulties. Has significant seasonal allergies managed by Sudafed and Flonase.
- CV: Denies history of HTN, MI, chest pain, palpitations. No edema in LE.
- Respiratory: Denies SOB except for CC episode. Has morning cough, which he attributes to his many years of smoking. Sputum clear, no blood. No history of pneumonia or asthma.
- GI: Appetite good. Loves to cook rich foods and desserts. Denies abdominal pain, nausea, vomiting, diarrhea, constipation.
- MS: Complains of occasional left shoulder pain. No known injury. Pain sometimes limits activities. Denies swelling, redness, decreased ROM.
- GU: Denies nocturia or dysuria.
- Neuro: Denies HAs, dizziness, confusion. Was light-headed with episode (see CC).
- Endocrine: Denies polyphagia but states he drinks large amounts of water due to living in a warm climate, so he urinates frequently. Denies cold intolerance, weight gain, bradycardia.
- Psychiatric: Denies history of depression in family or self.
Physical Examination
- Vital signs: T 99.0, BP 138/84, HR 80, RR 14, BMI 22.5.
- General: Alert and cooperative, posture erect, gait study, in no distress.
- HEENT: PERRLA, EOMs parallel, full peripheral vision. Retina clear, disc margins sharp. Thin gray hair. Facial expressions symmetrical. Posterior pharynx without lesions, inflammation. No cervical lymphadenopathy. Thyroid not enlarged or nodular. Weber shows no lateralization and Rinne AC greater than BC. Able to hear whispered word at 2 feet.
- CV: RR&R, no murmurs, S3 or S4.No JVD. No carotid bruits. No LE edema.
- Respiratory: Clear A&P. Nonproductive cough. A-P/lateral ratio 1:2. Costal angle less than 90.
- Abdomen: Soft, no tenderness, masses, bruits. No organomegaly.
- MS: Good muscle tone, strength equal, 5/5 in all four extremities. Full ROM in all four extremities and spine. Slight crepitus in left shoulder, but no restriction to movement.
- Neuro: A&O × 4. CNs II to XII intact. DTRs 2+ bilaterally, negative Romberg.
Questions
1. What are the differential diagnoses for this patient?
2. What diagnostics do you want to order?
3. What is the final diagnosis?