Reference no: EM133848345
Assignment
Subjective
CC: Chest pain
HPI: A 67-year-old female was recently discharged from the hospital a week ago from an NSTEMI s/p DES x 2 and PE. She reports recently developing left-sided pleuritic pain, which improves with sitting up and worsens when laying down. Pain is non-radiating without diaphoresis or nausea/vomiting. She denies fever or chills. Reports shortness of breath that initially was with activity but has progressed too constantly. She has a non-productive cough that worsens at night when lying flat. Reports swelling to lower extremities and had to remove rings due to hand swelling. She also has noticed that her pants feel tighter, and her abdomen is distended. She does not have a scale at home to check for weight gain.
Home Medications:
1. Eliquis 5mg BID PO
2. Prednisone 40mg Daily PO
3. Atorvastatin 40mg PO @ HS
4. HCTZ 25mg Daily PO
5. Fluticasone inhaler 2 puffs daily
ALLERGIES:
1. No Known Drug Allergies
PMH:
1. NSTEMI s/p DES x2
2. Hypertension
3. Hyperlipidemia
4. COPD
5. PE
SURGICAL/PROCEDURES:
1. Heart Cath with DES
SOCIAL:
1. Smoke history: Daily for 50 years
2. ETOH abuse/use history: Denies
3. Substance abuse/use history: Denies
FAMILY HX:
1. Unknown
REVIEW OF SYSTEMS:
1. As per HPI.
Objective
1. Temp: 98.3 Heart Rate: 161 Respiratory Rate: 28 Blood Pressure: 152/88 SpO2: 92% RA
PHYSICAL EXAMINATION:
1. Constitutional: Ill appearing adult female. Well-developed with central obesity.
2. Eyes: Conjunctivae are clear without exudates, hemorrhage, and edema. Non-icteric. PERRLA. No lesions were noted.
3. ENMT (Ears, Nose, Mouth, Throat): Nasal mucosa is pink and moist. Oral mucosa is pink and moist in color. No inflammation was noted to the mouth, throat, or ears. No tonsillar enlargement or foul odor from the mouth.
4. Neck: Supple without adenopathy. Trachea midline. Carotid pulses +2 bilaterally. Positive JVD and JVP around 12. Passive ROM to neck and head. Respiratory: The chest wall is symmetrical. No signs of trauma. Lungs fields are diminished to auscultation, breathing is currently labored, but no use of accessory muscles.
5. Cardiovascular: External chest wall is normal in appearance, without lifts, heaves, or thrills. PMI is palpated at the midclavicular line. No audible gallop auscultated. Murmur noted. Tachycardiac and irregular with friction rub. Positive edema to lower extremities with anasarca. Pulses are palpable to upper and lower extremities +2/+2. Cap refill about 3 seconds. Carotid pulses are present bilaterally.
6. Gastrointestinal: Aorta midline without bruit or visible pulsation. The umbilicus is midline without herniation, and no masses were noted. Positive hepatojugular reflux. Soft to palpation, round. Bowels are active in all 4 quadrants.
7. Genitourinary: Genitalia not examined. No pelvic tenderness or bladder distention on palpation.
8. Musculoskeletal: Upper and lower extremities are atraumatic in appearance without tenderness or deformity. Deep tendon function is normal. Pulses palpable. Skin: No lesions, rashes, or mass noted. Cool and dry. Normal hair distribution throughout. Neurologic: Responsive. Motor function present. The sensation is intact bilaterally. Psychiatric: Alert, oriented, flat affect with positive eye contact.
Labs:
1. WBC 7; Hbg 9; Hemat 23; Plts 51; Sodium 151; Potassium 3.2; Glucose 140; BUN 38; Creatinine 1.82; Albumin 1.9; AST 143; ALT 296; Mag 1.8; Lactate 3; BNP 453; Troponin-I 5.39.
EKG: Atrial Fib RVR 161
CXR: Increasing density of multifocal opacities greater on the right with cardiomegaly.
CT Chest w/wo contrast:
A. Multifocal airspace disease in the lungs is characterized by ground-glass opacities, nodular opacities, and areas of focal consolidation
B. Superimposed mild interstitial edema is also suggested with small bilateral pleural effusions
C. Small Pericardial effusions
D. Trace perihepatic ascites
ECHO on the last admission- EF 50% with grade one diastolic dysfunction with left ventricular hypertrophy. Trace regurgitation with elevated PA pressure.
Task
A. Based on the case study, create a problem representation for the case study.
I. Only include pertinent positive and negative information (Do not read this entire case study verbatim).
II. What are your initial differential diagnoses? Get the instant assignment help.
III. What diagnostic would you consider ordering for this patient to "rule in" or "rule out" a diagnosis?
IV. What is your plan for this patient (use clinical practice guidelines)?
B. Did you utilize any tools to help guide this plan (i.e., HEART, CHADVasc, HAS-BLED score, etc.)?
C. How could we have prevented this re-admission by evaluating this patient's previous admission?
D. Pose two open-ended questions for your peers to respond to regarding questions you may have experienced researching the topic or required unit material.