Reference no: EM132372187
CASE STUDY 22-2
Arthur Cochran is o 58-year-old patient who lives at 45 W. Smith Avenue, River City, XY 01234. His date of birth is July 8, 1954. His phone number is 410.667-1870. He is a Baltimore city fire fighter and has been for 21 years. He has union medical insurance, and Blue Cross/Blue Shield (Beigs)is his carrier.
His number is 211-67-87-56. He also carries major medical, and his policy is Diagnostic #4. He hos been referred by the fire deportment practitioner, Dr.Alan Byers.Mr.Cochron's complaint is severe "gripping" pain in the anterior mid-chest sometimes radiating to the abdomen, neck and both arms. Pain seems to occur with strenuous exercise and when walking uphill. Pain usually lasts 20 minutes with each episode. Pain does "ease up" when he ceases activity. Mr. Cochran slates his episodes have occurred while he was shaving, while climbing stairs at work, offer o heavy meal, and during sexual intercourse.
One episode last week was accompanied by dizziness, nouseo,and fatigue. The episodes have been going on now once or twice a month for 5 months. Mr.Cochran's history is essentially noncontributory. It is questionable whether this is due to good health or the fact that the patient has not had a physical examination for 8 years. Surgeries include tonsillectomy and adenoidectomy (T&A) in 1958, and appendectomy in 1964. He had a fractured rib, left side,in 1984 due to a fire-fighting incident. Usual childhood diseases.
Hospitalized for observation, 1962, Sinai Hospital, for on unusually long episode of bronchitis. Social history shows that the patent is a pump operator on the job with much heavy exertion. Smokes 11/2 to 2 packs of cigarettes per day and is a moderate drinker. He has a weight problem off and on and tends to eat too much while on duty. Lives in a one-story home. Hobbies include carpentry and music. Some family problems and tension exist as both of his children are in adolescence. Patient describes himself osluntaall with a "quick temper and worries about meeting financial needs of the family. He is in o position40 retire from active duty but states he could not tolerate the boredom.
Family history shows both parents deceased—mother of heart attack, age 59, and father of unknown cause of age 49. Has two siblings, one brother with history of hypertension and one sister living and in good health. Has two children both living and well. Family history otherwise negative.
Physical examination revealed a well-nourished, well-developed male in no acute distress this time. Patient does seem a bit anxious about Ihis examination. T. 98.6, P. 94, R.24, BP 175/104.
Ht: 69 inches, Wt. 198 pounds. HEAD, EYES, EARS, NOSE, THROAT—normol . NECK—supple.Trochea in midline.CHEST—normol in contour.Colcium deposit on left sixth rib probably due to history of fracture. HEART—offer careful examination with the patient recumbent and the scope placed lightly on the chest wall near the apex, o left atrial sound was heard (presystolic gallop). ABDOMEN—negative. EXTREMITIES--negative. GENITALIA—negative. SKIN—negative. NEUROLOGIC—negative. Laboratory tests performed show a hemoglobin of 11.0 gms. Awaiting results of serum cholesterol, calcium, phosphorus, and blood urea nitrogen. Chest radiograph essentially negative. EKG report showed atrial sounds occurring presystolicolly with long P-R intervals.
DIAGNOSIS:
(1) angina pectoris;
(2) anemia;
(3) hypertension.TREATMENT: Nitroglycerin tabs, sublingually as needed.
To return to clinic in 2 weeks to follow medication effects. In consultation with patient, the patient was advised to control physical activity and quantity of food intoke.Avoid extreme cold,8 hours of sleepinight.Avoid emotional upsets. Attempt four meals/cloy. Low-fat 1,600-calorie diet. No smoking, moderate alcohol intake.
CASE STUDY REVIEW
1. Identify the following ports of the case study above and extract from the case study the portion that matches the appropriote medical history component.
Personal data
Chief complaint
Present illness
Medical history
Family history
Social history
Review of systems
2. Using appropriate terminology and abbreviations, make a charting entry for Mr. Cochran by using the SOAPER method of charting.