Chief Complaint: chest pain and “heavy” breathing
HPI: 7 year African American female brought in by mother today for c/o chest pain and
difficulty breathing. Mother states that pt threw up last week on 2 separate occasions at
school after running. Mother also reports that she has noticed the patient breathing
"heavy" at times and appearing to have difficulty catching her breath. She reports that the
patient has complained about the chest pain "several" times during the past 2 days and
last night when the patient reported the pain the mother felt that it was time to have the
pain assessed. Pt reports that the pain is midsternal pain, which does not radiate. She
states that the pain hurts enough to make her stop talking or participating in activities but
not enough to make her cry. She reports that the pain often occurs while she is riding
home on the school bus but does not appear to be associated with any other factors or
symptoms. Pt reports occasional regurgitation when she get “really full” or lies down.
Denies palpitations, radiating chest pain. Reports “heavy breathing” with midsternal pain.
Unable to describe pain characteristics. Denies any relationship to PO intake or activity.
However, mother reports that the patient has been eating “a lot of tomatoes recently” and
states that this has become her “new favorite food”. Mother reports that pt has not had
any medications for her chest pain, but states that last night when the pain began she
offered her daughter milk and states that the pain was relieved within a few minutes.
Current Health Status:
Allergies: NKDA, NKA
Medications: pt is not currently taking any medications
PMH: Pt has no previous medical or surgical history. No hx of trauma or hospitalization.
Immunizations are current and up to date (on file). Pt missed her last well child
appointment at age 7 and mother denies having it done by another provider. Pt lives with
her mother and father in a nearby home. Pt has 1 older sister who also live with her. Pt
attends public school and is currently in 1st grade. Pt reports that she enjoys school and
makes “good grades”. Mother denies pt having any learning difficulties or behavioral
concerns. No exposure to cigarette smoke, animals, harmful chemicals, or persons with
illness. Pt eats a regular diet and is active. Family history positive for HTN (father, and
aunt), DM (paternal grandmother). Mother also reports that mother’s aunt had breast
cancer but states that she is currently in remission.
ROS:
General: Pt/mother denies chills/headache /lethargy/weakness/fever/diaphoresis/hot or
cold intolerances or changes in body temp. Denies changes in appetite, but reports a
recent increased dietary intake of tomatoes. Denies changes in sleep patterns. Mother
denies any obvious change in pt’s weight but reports that she does not weigh her daughter
except when she comes to the doctor.
HEENT: She denies headache, dizziness, confusion, loss of consciousness. Denies
visual/hearing changes or disturbances. Denies ear/eye
pain/discharge/swelling/redness/itching. Denies rhinorrhea or history of seasonal
allergies, denies any nasal discomfort, or epistaxis. Denies mouth pain/discomfort.
Denies dysphagia/sore throat/hoarseness/swollen glands/vertigo/hair loss/ neck pain or
stiffness. Thyroid enlargement noted.
Cardiac: Pt reports intermittent chest pain. Mother reporting that she has noticed pt
having “heavy breathing” at times. Pt states that she “sometimes” feels short of breath.
No chest heaviness, radiating pain, or tightness. No leg or calf pain/swelling
Respiratory: Denies cough, audible breath sounds/wheezing, paroxysmal nocturnal
dyspnea, hemoptysis. Denies changes in pitch or tone of voice, or abnormal sounding
cough.
GI: Pt reports that she has been having occasional nausea after eating for a “couple of
weeks” and reports that she vomited on 2 separate occasions last week. Denies vomiting
since last week. She reports occasional regurgitation when she gets “really full” or when
she lies down. Pt denies diarrhea/excessive salivation; Denies abdominal pain/bloating.
She reports daily bowel movements with no changes in bowel patterns (frequency, color,
or consistency). Denies blood in stool. Mother reports recent increase in intake of
tomatoes but otherwise denies changes in dietary patterns. Denies belching, flatulence or
fecal incontinence. Reports esophageal mid-sternal pain/burning.
GU: denies urinary frequency, pain, burning, hesitancy, urgency, or incontinence. Denies
hematuria/oliguria. Reports that urine is clear and yellow and she has not noticed any
odor.
MSK: Denies muscle pain, limitation of ROM or ADLs. Denies having any recent
injuries, hx of trauma or fractures.
Developmental/school: Pt/mother denies any developmental limitations or concerns. Pt
reports that she likes school and gets along well with her peers. Pt able to pay attention
and stay on task both at home and in school. Mother reports pt able to differ between
right and wrong and does not tend to have excessive impulsivity.
Psych/Neuro: Denies any sudden loss of consciousness/unsteady gait. Denies history of
seizures/anxiety/depression/sleep disturbances. Denies irritability/apathy/irritability/mood
swings.
Physical Exam:
General: Height: 52”, weight: 75lbs, BMI 19, BP 113/75; HR 81; Temp 98.4; Resp 26;
Pt A&Ox4, no resp distress/SOB/accessory muscle use at this time. Pt is well
nourished/hydrated. Well developed. Smooth gait and posture. Nail beds pale and
smooth, clean, with clubbing. Capillary refill < 3 seconds. Skin pink and warm, no
cyanosis/petechiae noted. Good turgor.
HEENT: Head normocephalic, symmetric, holds erect and midline. PERRLA,
conjunctiva and lacrimal system are without discharge or erythema; Sclera white; no
ptosis; no periorbital edema present; all extraocular movements are present without
nystagmus or fasciculation’s. No strabismus. Ears are nontender, without
erythema/lesions/discharge/abnormal growths. External cartilage is firm without any
palpable indurations. External auditory canals are clear. Bilateral tympanic membranes
are patent and appear pearly gray with a present light reflex, bony landmarks noted in
both ears; no bulging or erythema noted. Nose is midline, no lesions noted on exterior
surface; no nasal flaring or narrowing. Nares are patent. Nasal Cartilage is firm and nontender. Septum is midline, intact without perforations; no crusting, lesions, or polyps
noted. Turbinates are not enlarged, erythematous or inflamed, no rhinorrhea noted.
Dentation intact. Upper central incisors and lower lateral incisors intact. Oral mucosa
pink and moist. No lesions of mouth noted. Normal pharynx. Uvual rises evenly, gag
reflex intact. Neck supple, nontender, no masses or nodules, trachea midline, no goiter.
Thyroid enlargement noted, rises evenly and symmetrical. No lymphadenopathy noted.
Cardiac: Denies chest pain/discomfort at this time. No neck vein distention, rate and
rhythm regular and normal, S1 and S2 present, no rub/gallop/murmur/clicks auscultated.
No thrill or heaves noted. No edema. Pulses +2 and symmetric throughout. Extremities
pink and temp warm to touch. Hair evenly distributed on all extremities.
Respiratory: Respirations even and unlabored. No audible breath sounds/accessory
muscle use noted. No hyperresonance with percussion.
GI: Abdomen soft, nontender, nondistended. Bowel sounds present x 4. No ascites
present. No rebound tenderness/nodularities, or enlargement of liver or spleen noted. No
hernias. No protrusions. Umbilicus is midline and inverted. Last BM yesterday per pt.
GU: No bladder distention and nonpalpable. No CVA tenderness
Skin: color is consistent throughout, no
cyanosis/lesions/masses/discolorations/rashes/ecchymosis.
Msk: No scoliosis, shoulder and hip placement even and symmetrical bilaterally. Muscle
tone and strength equal bilaterally. DTRs intact.
Developmental: Pt has normal hand/eye coordination, maintains balance appropriately.
Pt able to state day of the week and month. Vocabulary and mentation appropriate for
age.
Diagnostics: Pt has no c/o abdominal pain/discomfort. Pt given orders today for chest
xray and EKG, and CBC to r/o cardiac involvement. (Hollier & Hensley, 2011). Also
ordered TSH as thyromegaly noted upon physical exam. Will call mother with results and
treat accordingly. If serum TSH is high, I would order a free T4 to determine the extent
of hypothyroidism but more likely if serum TSH is low, I would order both a free T4 and
T3 to determine the degree of hyperthyroidism. (I would also check for presence of H.
Pylori to r/o infection and possible PUD- Lehne, 2010)
Medical Diagnosis and Plan:
1. GERD (530.11)- Suspect GERD due to presenting symptoms of regurgitation
upon satiety, recent increase in acidic foods (tomatoes), recent changes in diet and
rapid relief from milk. Due to possibility of cardiac involvement and possible
future acute episodes, pt was given orders and sent to hospital for EKG and chest
xray as well as CBC (McCance, 2010).
Differential Diagnosis:
1. Cardiac Disease- This diagnosis is possible based on presenting symptoms. Will
perform diagnostics such as chest xray and EKG to r/o any cardiac involvement
(Hollier & Hensley, 2011).
2. Esophageal Spasms/infection- CBC will help determine presence of infection
and also ordered chest xray which will show anatomical structure and any
abnormalities (Hollier & Hensley, 2011).
3. Eosinophilic Esophagitis:- This diagnosis is becoming increasingly recognized
with advanced technology and should be ruled out. This is not a likely diagnosis
as the pt denies dysphagia and/or abdominal pain which are 3 of the most
common presenting symptoms in children. However, this diagnosis remains
possible for this patient as she does report symptoms resembling GERD as well
has positive hx for vomiting (Bonis et al., 2013). Recommended diagnostic
studies such as an upper endoscopy and esophageal biopsy could be ordered if pt
not responsive to lifestyle and dietary modifications, or unresponsive to
medications and pt had no improvement with less invasive therapies.
Teaching: Cg instructed to have pt avoid eating 2 hours prior to bedtime and to have pt
sit upright after eating (Dunphy, 2007). Mother also instructed to have pt avoid eating
offending foods such as acidic such as fruits and fruit juices as well as some vegetables
including tomatoes, spicy and/or fried foods, chocolate, peppermint, and caffeine.
(Hollier & Hensley, 2011). Instructed pt to avoid eating tomatoes more than 1-2 per week
as this may be causing her to have upset stomach. Instructed pt to avoid tight fitting
clothing. If lifestyle modification is not successful, then pharmacological therapy such as
PPIs (omeprazole) or antihistamine type 2 receptor antagonist (Tagamet) could be
utilized (Lehne, 2010).
References:
Bonis, P.A., Furuta, G.T. (2013). Pathogenesis, clinical manifestations, and diagnosis of
eosinophilic esophagitis. Retrieved on July 3, 2013 from
http://www.uptodate.com/contents/pathogenesis-clinical-manifestations-anddiagnosis-of-eosinophilic-esophagitis?source=see_link
Dunphy, L.M., Winland-Brown, J. E., Porter, B.O., & Thomas, D. J. (Eds.). (2007).
Primary care: the art and science of advanced practice nursing (2nd ed.).
Philadelphia: F. A. Davis.
Hollier, A. & Hensley, R. (2011). Clinical guidelines in primary care: a reference and
review book. Lafayette, LA: Advanced Practice Education Associates, Inc.
Lehne, Richard. (2010). Pharmacology for nursing care. (7th edition). St. Louis, MO:
Saunders Elsevier.
McCance, K.L, Huether, Sue. (2010). Pathophysiology: the biologic basis for disease in
adults and children. (6th edition). Maryland Heights, MO: Mosby Elsevier.