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Written Case Study- Dallas Dooley 67 year old Caucasian malePMH: Coronary artery atherosclerosis Hypertension Hypercholesterolemia Depression Exercise intolerance ConstipationSurgeries: Coronary Artery Bypass Graft (CABG) 12/2012Health Promotion: Colonoscopy 2008, Treadmill Stress test 12/2012, Tetanus immunization 2009, PSA was normal 2010, Pneumonia vaccine 2012Recent Illness: Recurrent otitis Media and upper respiratory tract infection in Feb-March 2013Medications: 1) Lovastatin 20 mg daily 2) Stool Softener 1-2 tabs as needed 3) Ferrous Sulfate 325 mg B.I.D 4) Aspirin 325 mg daily 5) Atenolol 50 mg dailySocial History: Married for 42 years to the same woman, has two grown children, practicing Catholic that is very involved in the local church. Smoked a pipe 4-5 times a day prior to the CABG, has cut down to 1-2 times a day now. Denies Etoh or drug use. He is self-employed as a farmer.Family History: Mother: Unknown; Father: CAD, Pacemaker, CABG and depression, maternal grandmother: died of cancer at age 78, paternal grandfather died of prostate cancer at age 90. Brother: has hx of prostate cancer. Chief complaint: Patient complains of intermittent chest pain and shortness when he walks or does simple jobs. HPI with essential elementsO- Chest pain and shortness of breath has been present for a very long time, but noticed it getting worse 6 months ago. States that the pain is very minor since his CABG surgery in 12/2012, although still has shortness of breath.L- Pain is located in the chest, although when he gets short of breath, he notices that his legs get very weak D- Shortness of breath has been present for 6 months, along with the chest pains/pressure. C- Describes the chest pain as a tight pressure in the chest. He feels like he has trouble catching his breath as well. A- Exercise, working on the farm and moderate to extreme exertion makes the pains and shortness of breath worse.R- Both symptoms tend to diminish with rest. T- Takes Mucinex because he feels like he has a “chest cold”, takes ASA 325 mg daily and his atenolol daily. asHas not taken any other medications or treatments. S- When the chest pressure is present it is rated at a 4/10, a tight pressure on the chest.ROS (16 point).Constitutional symptoms (fever, weight loss) –Weakness that has been present since his CABG in 12/2012. States that he often becomes sad and states to cry. Patient feels like he is going to die soon.Eyes- normal Ears, Nose, Mouth, and Throat – Complaining of pressure in the ears and sinus congestion for the past two weeks. States that he gets headaches and feels very congested in his sinuses. Cardiovascular – has intermittent chest pains and pressure. C/o shortness of breath with exertion. Respiratory- Shortness of breath with exertion. States that he is not able to walk on his treadmill more than 10 minutes at a time since his CABG surgery. Reports that he gets short of breath doing simple tasks on his farm Gastrointestinal- negativeGenitourinary- negativeMusculoskeletal- c/o generalized muscle aches. Non-specific. Patient feels like his legs are weaker than they used to be.Integumentary (skin or breast) - negativeNeurological- negativePsychiatric- Patient states that he gets very sad and starts to cry. Patient states “I’m just getting old, and it depresses me”. Patient states that he gets very anxious when he working and starts having shortness of breath. While waiting in the waiting room today, she states that he had to go to his car because he started crying. Patient also reports that he doesn’t not want to go to a cardiologist because it scares him. Denies any suicidal or homicidal ideation. Patient also has lack of interest in doing the things that he used to do like working in his shop. He is fearful of dying while working in the shop.Endocrine Hematologic/Lymphatic- negativeAllergic/Immunologic- negativePhysical Exam FindingsVS: BP 122/60, Pulse 64, Resp. 18, Temp 98.6, O2 sat 99% on room air, weight 174 lbs., height 66 inGENERAL: A/Ox4 male that is slightly disheveled today. Appears to be anxious and tearfulPSYCH: Patient is tearful when speaking. Patient gets very agitated when talking about his CABG surgery, and states that he should be feeling better by now. HEENT: Head is atraumatic and normocephalic, ears have normal light reflex bilaterally with no erythema or effusion, throat is pink and moist with no exudate although there is clear drainage and posterior pharynx is red, turbinate are beefy red color with clear discharge, eyes are PERRLA with 3 mm pupils, EOM movements are all intact, no nystagmus present. Pain to frontal and maxillary sinuses on palpationNECK: supple with no lymphadenopathy, thyroid gland is not palpable, no JVD, carotid pulses +2, and no carotid bruise auscultatedLUNGS: Breath sounds clear and equal bilaterally. No egophony noted. Resonance percussed throughout the entire bilateral lung fields.CARDIAC: S1 & S2 was auscultated, normal rate and rhythm, no murmurs or gallops noted. PMI located mid clavicular. ABDOMEN: Abdomen soft and non-tender, bowel sounds were active in all four quadrants, no splenomegaly or hepatomegaly noted. No hernias or nodules palpated over the abdomen. No abdominal pain on palpation.EXTREMITIES: 4/5 strength to bilateral upper and lower extremities, 2+ radial, carotid and pedal pulses bilaterally, 1+ pedal non-pitting edema, no clubbing or cyanosis, limited ROM to shoulder, pain on passive ROM. Full ROM of elbows, wrists, hips, knees and ankles. NEUROLOGICAL: Cranial nerves II-XII intact, strength is 4/5 in upper and lower extremities, 2+ deep tendon reflexes throughout, normal Romberg test, slow gait but no ataxia notedSKIN: CABG scar to mid sternum, skin is pink, warm and dry.TESTS: Stress Test with echocardiogram was administered in 12/2012, prior to the CABG. Patient had syncopal episode while walking on the treadmill for the stress test. Labs Collected on 3/10/13TSH: 2.40Cholesterol Levels: Total Cholesterol 140 Triglycerides 169 HDL 40 LDL 92CBC: normal, no abnormalitiesComprehensive Metabolic Panel: BUN 22 Creatinine 0.9, Glucose 105 mg/dL all other panels were WNLTNI: 0.01- normalPSA: 1.2 Chest Xray: evidence of CABG surgery, mild cardiomegaly, no atelectasis, no infiltrates foundEKG: Heart rate was 64, sinus rhythm. He had T-wave inversion in V1, V2, V5, and V6. EKG interpretation was read as left atrial abnormality; ST and T wave abnormality considered anterolateral ischemia or left ventricular strain.Differential DiagnosesAngina- this diagnoses is r/t the intermittent chest pressure and shortness of breath with exertion. Angina is considered due the recent CABG and lack of follow-up with the cardiologist. The shortness of breath and chest pressure also seems to subside with rest as well. This case presents two relevant final diagnoses. Angina is the #1 differential diagnoses. Acute Sinusitis- this diagnoses with r/t the maxillary and frontal sinus pressure, along with erythema to the posterior pharynx along with red and beefy colored turbinate. This is also a very relevant diagnosis, but is not a primary diagnoses. Depression- this diagnoses is considered due to the fear of getting old, along with frequent crying spells and tearfulness during the exam. This is also relevant due to the lack of interest and fear of the tasks that he used to perform. He is also very scared of dying. This is the #2 primary differential diagnoses.Hypothyroidism- this diagnosis can be considered due to the weakness, and intermittent shortness of breath. This diagnosis can be considered because a TSH lab test has not been collected for several years. Congestive Heart Failure- this diagnoses is considered to the history of coronary artery disease, along with 1+ edema to the lower extremities. CHF is considered as a primary diagnoses due to the shortness of breath as well. This diagnosis was ruled out because recent echocardiogram reported a 60% EF, and a BNP one month post-CABG was 50 (normal).Plan: At this point in time I will provide patient with a prescription for Nitroglycerin 0.4 mg SL. I have instructed the patient to take the Nitro when he experiences chest pain. He can take 1 tablet SL every 5 minutes for 3 doses. If he continues to the experience chest pain that radiates down the left arm or to the left jaw, he is to call 911. I will also encourage patient to continue to rest until he sees the Cardiology. I will contact Dr. Kumar with St. Francis Cardiology, and schedule a follow-up appointment for this patient. Upon evaluation of Dr. Kramer, I will encourage cardiac rehab every day for this patient. I will call the patient with the appointment time and date. I will also start patient on Lexapro 10 mg by mouth daily. I will start Lexapro for the depression symptoms that are being displayed at this time. If sinusitis symptoms do not subside within 7 days, I will have him follow up in the clinic and I will consider starting Augmentin or Zithromax antibiotics. Patient agreed to follow-up with Cardiology and will start cardiac rehab upon clearance from Dr. Kumar. Patient will not start the Lexapro because he does not feel that he is depressed. He will call in one week and report any other symptoms.Reflect on the care given:I feel that the care given was satisfactory. Since this was a somewhat difficult case to shift through, I felt that I prioritized by differential diagnoses, and addressed the most critical diagnoses first. I feel that I should I have completed a depression scale on the patient, I did not do that. This is something I will definitely do on the next patient that presents in the way. Another thing I would do is speak to the patient about involving his wife into the plan of care. I failed to do this in this case. I feel that I practiced evidence based practice by not placing him on an antibiotic for the sinusitis immediately. I also feel that I followed evidence based practice by ordering and interpreting the appropriate lab tests and diagnostic tests. I also feel that I practiced evidence based practice by scheduling an appointment with the cardiologist as soon as possible. I also should have considered the use of diuretics to alleviate the edema to the lower extremities, that could also help with the shortness of breath symptoms even though the chest x-ray did not relief pulmonary congestion. Overall I am satisfied with this patient interaction. ................
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