Written Case Study- Dallas Dooley
1.
67 year old Caucasian male
2.
PMH:
Coronary artery atherosclerosis
Hypertension
Hypercholesterolemia
Depression
Exercise intolerance
Constipation
Surgeries: Coronary Artery Bypass Graft (CABG) 12/2012
Health Promotion: Colonoscopy 2008, Treadmill Stress test 12/2012, Tetanus
immunization 2009, PSA was normal 2010, Pneumonia vaccine 2012
Recent Illness: Recurrent otitis Media and upper respiratory tract infection in Feb-March
2013
Medications: 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 daily
3.
Social 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.
4.
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.
5.
Chief complaint: Patient complains of intermittent chest pain and shortness when he walks or
does simple jobs.
6.
HPI with essential elements
O- 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. Has 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.
7.
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- negative
Genitourinary- negative
Musculoskeletal- c/o generalized muscle aches. Non-specific. Patient feels like his legs are
weaker than they used to be.
Integumentary (skin or breast) - negative
Neurological- negative
Psychiatric- 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- negative
Allergic/Immunologic- negative
8.
Physical Exam Findings
VS: BP 122/60, Pulse 64, Resp. 18, Temp 98.6, O2 sat 99% on room air, weight 174 lbs.,
height 66 in
GENERAL: A/Ox4 male that is slightly disheveled today. Appears to be anxious and tearful
PSYCH: 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 palpation
NECK: supple with no lymphadenopathy, thyroid gland is not palpable, no JVD, carotid
pulses +2, and no carotid bruise auscultated
LUNGS: 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
noted
SKIN: 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 3/10/13
TSH: 2.40
Cholesterol Levels: Total Cholesterol 140
Triglycerides 169
HDL 40
LDL 92
CBC: normal, no abnormalities
Comprehensive Metabolic Panel: BUN 22 Creatinine 0.9, Glucose 105 mg/dL all
other panels were WNL
TNI: 0.01- normal
PSA: 1.2
Chest Xray: evidence of CABG surgery, mild cardiomegaly, no atelectasis, no
infiltrates found
EKG: 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.
9. Differential Diagnoses
A. Angina- 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.
B. 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.
C. 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.
D. 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.
E. 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).
10. 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.
11.
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.