Case Study
Chest Pain
Kathleen Cornell, FNP student
SUNYIT
March, 2014
Demographics
 Patient: JD
 Age: 36 years
 Gender: Caucasian female
 Height: 5’4”
 Weight: 201
 BMI: 33 (overweight)
 Source of encounter: Community Health Clinic. Referral
from the emergency department of Saratoga Hospital for
follow up diagnosis of Pleurisy
Chief Complaint
 36 Year old Caucasian female complaining of chest
pain left pectoral area that radiates down left arm on
occasion. Currently, the pain level to the chest is an 8
out of 10, has no relief from pain medication, or rest.
The pain does not increase with inspiration or
expiration and does not radiate into back, jaw, or right
side, nothing makes it worse or better. It is not
reproducible with palpation. States she has on
occasion a rapid heart beat at rest with shortness of
breath, but the shortness of breath is with ambulation.
Patient states she was in the emergency room ten days
prior to this visit and, “they diagnosed me with
pleurisy”.
History of Present Illness
 36 Year old Caucasian female presenting for a follow-up
visit regarding emergency room diagnosis of Pleurisy.
 Ten days prior to this visit, the patient was in the
emergency room for complaints of chest pain across her
chest for greater than 24 hours, no arm or jaw pain at the
time. Patient states the pain is located at left chest wall
pectoral area on occasion it will radiate with tingling down
her left arm. Currently the pain is an 8 out of 10, and is
constant throughout the day. It does not increase or
decrease with movement or inspiration/expiration. Not
reproducible with palpation to site.
History of Present Illness
 States it sometimes gets worse at night when sleeping
it will cause her to wake up. States my boyfriend tells
me I snore really loud lately. The pain is
crushing/stabbing like someone is punching her. She
has had no previous history of chest pain.
 Gets light headed and short of breath on occasion
with walking.
Past Medical History
 Medications: Chlorathalidone 25 mg QD, Flexeril
10mg QD
 NKDA, allergy to bee sting causes anaphylaxis, no
food or latex allergy
 Past Surgical History: Gallbladder 03’, Right ankle
tendon repair 05’, Tubaligation 05’
 Immunizations: Last tetanus 08’, Flu vaccine 13’, not
sure of other immunizations
Family History
 Three children – two boys, 15, & 9, one girl – 12
 One miscarriage, one termination
 Parents: Maternal grandmother had CHF, Father
deceased 35 years – O.D., Mother alive 56 years
alcoholic, low B/P, siblings – one brother 32 yr – well,
one sister 33 yr - well
Social History
 Works at Price Chopper as cashier day shift full time.
Started work two months ago.
 Smokes 10 cigarettes a day for 15 years, waiting for
patches to arrive will be quitting.
 Alcohol once a month socially, no street drugs in the
past or current.
 Lives with boyfriend in an apartment, has vehicle for
transportation, wears a seatbelt while driving and
passenger, active with children’s activities with school.
Denies physical or emotional abuse.
ROS
General: Denies fever, chills, weight loss or appetite change
Skin: Denies excessive sweating, changes in hair or nails
Head: Positive for headaches over last year, saw a physician
had negative review. Positive for dizziness with ambulation on
occasion.
Neck: Denies lumps, pain on ROM, stiffness, or goiter.
Ears: Denies ringing in ears, hearing loss, pain, use of hearing
aids, denies exposure to excessive noise.
Eyes: Denies visual changes, infection, sensitivity to light, does
not wear glasses, double vision, glaucoma, or cataracts.
ROS
 Nose & Sinus: Patient denies change of smell, nasal
obstruction, infections, nose bleeds, hay fever, sinus
pain or infection.
 Mouth & Throat: Denies hoarseness, dryness, ulcers,
bleeding gums, abscess to gum, tonsils or soft tissue,
denies taste disturbance. Has all teeth with fillings in
back molar region upper and lower.
 Respiratory: Denies wheezing, positive cough for
several weeks, short of breath with walking on
occasion, denies emphysema, asthma.
ROS
 Cardiac: Positive for chest pain, palpitations on
occasion, denies murmurs, positive for high blood
pressure for one year. Denies, previous MI, angina or
EKG changes.
 Peripheral vascular: Denies leg pain, vericose veins or
past leg clots.
 Gastrointestinal: Denies appetite loss, positive for
heartburn, no vomiting. Denies jaundice,
constipation, diarrhea, ulcers, gallstones, or tumors
ROS
 Urinary: Denies frequency, burning on urination,
urgency, blood in urine. No STD’s, sores, pain to
labia/vaginal area.
 Musculo Skeletal: Positive for pain down left arm on
occasion feels more like tingling and tightness. Denies
stiffness to joints, deformity, swelling, full range of
motion, back pain, difficulty with ambulation.
 Neurological: Denies abnormal thoughts, remote and
recent history intact, seizure disorder, paralysis,
weakness, fainting, stroke. Positive for occasional
tingling/numbness to left arm radiating to fingers.
ROS
 Hematological: Denies anemia, blood transfusions,
easy bruising.
 Endocrine: Denies diabetes, thyroid disease or
hormone therapy.
 Psychiatric: Denies tension, mood changes,
hallucinations, or paranoia. Has a history of
anxiety/depression.
OBJECTIVE
 General Appearance: Well developed, well nourished 36
year old Caucasian female, who is alert, oriented to person,
place, and time. Appears anxious with episodes of crying
during initial interview.
 Vitals: B/P – 177/118 left arm sitting, 152/109 right arm
sitting. P – 97, R – 18, O2 sat – 100% on room air, T-98.0,
Weight – 201lb, Height – 5’4”, BMI – 33.
 Head: Normocephalic, no lesions, scaling, hair distribution
even, brown.
 Skin: Pale, warm, dry, tattoo to left inner forearm 5cm in
length by 3cm wide, injected 2002. Nail beds 160 degree
angle, no clubbing, positive blanching 5 seconds. No
rashes, turgor taught.
OBJECTIVE
 Eyes: Symmetrical, pupils 3mm reactive to
consentual, convergence and close, red reflex noted to
both eyes. Conjunctiva without swelling, or redness,
sclera white without discharge. Eyelids equal in form,
EOM tested without extropia, or hyperopia. Last eye
exam 2013/11.
 Ears: Non tender tragus bi-lateral ears, external ear
canal without redness, swelling, or discharge, left ear
tympanic membrane at 7o’clock, cone of light
visualized, right ear tympanic membrane at 5o’clock,
cone of light visualized. Hearing without out deficit
both ears tested by Weber and whisper.
OBJECTIVE
 Nose/Sinus: Nostrils without flaring, symmetrical,
turbinates, pink without drainage, palpation of frontal sinus
negative for pain, olfactory nerve functional with smell of
coffee grounds identified.
 Mouth/Throat: Teeth intact with mercury fillings to
molars upper and lower, buccal pink, stenson’s ducts
visualized, soft and hard palate without swelling, lesions,
no swelling to gums, no deviation to uvula equal with rise,
tonsills visualized.
 Neck: Lymphatics, left and right preauricular, posterior
auricular, occipital, superficial cervical, submandibular non
palpable, Thyroid non palpable.
OBJECTIVE
 Chest/Thorax: Lungs clear on auscultation AP&
Lateral diaphragmatic excursion 5cm, respirations
equal chest rise symmetrical, no increase in AP
diameter. Does self breast exams most recent breast
exam was with yearly pap 01/14
 CV/PV: Heart sounds rate regular, rhythm regular, no
murmurs, S1 greater than S2. No heaves, thrills,PMI
5th LICS MCL, peripheral pulses 2+, dorsalis pedis
1+, no carotid bruit. Homan’s negative capillary refill
immediate.
OBJECTIVE
 Abdomen: Symmetrical, no scars, lesions, bowel sounds
high pitch over small bowel, tympany, no guarding or pain
on palpation, no organomegaly over spleen.
 GU: No complaints of pain on urination, frequency,
urgency, last menstrual cycle – 2/26/14, normal flow. Last
pap exam 01/14, normal.
 Musculoskeletal: Ambulates without assistance, full range
of motion to upper and lower extremeties, no increased
curvature of back, strength 5+ throughout.
 Neurological: Speech intact, appropriate for age, oriented
to time and place, reflexes 2+ to bicep, tricep, quadricep,
achilles. Negative Babinski sign
Differential Diagnosis
 Nurse Practitioner assessment: R/O pulmonary
embolus
 My Assessment: Reflux, obstructive sleep apnea,
Hypertension
DIAGNOSTIC TESTS
 EKG, ECHO
 Labs: TSH, A1C, COMP, CBC, VIT. D, LIPID
PROFILE, URINALYIS, TROPONIN
PLAN

According to the patient’s history of smoking, give smoking
cessation information and teaching.

Review EKG with patient, get an Echocardiogram today have
patient return to office to discuss test results.

Review lab work with patient in one week.

Start patient on Ace Inhibitor low dose lisinopril 10mg QD

Norco 2.5mg Q 4-6 hours for pain as needed. 20 tablets dispensed

Review test results from Emergency Department.

Refer patient to Pulmonary for further evaluation of possible
Cardiopulmonary insufficiency, sleep apnea.
Epocrates. (2013)

Definitive reason for
Diagnosis
Hypertension: diagnosed when systolic B/P is greater than
140mmHg, or diastolic greater than 90mmHg. Blood
pressure is usually lower at night and the loss of this dip
shows an association with cardiovascular risk.
 The medication this patient is taking is classified as a
diuretic (Chlorthalidone), I would consider adding a ACE
inhibitor and get a baseline BUN/Creatinine level.
 Review CT scan from ER – showed no abnormalities, no
pulmonary embolism. EKG – showed normal sinus
rhythm, ECHO – showed no abnormalities. Blood work
showed normal troponin levels, labs within normal limits
except Potassium was 3.2.
 Papadakis, M., & McPhee, S. (2013).
Reason for Diagnosis
 Reflux – The feeling of burning radiating to the neck
caused by gastric acid material into the esophagus. One
third of patients experience chest pain of unkown origin.
50% have increased amounts of acid, this has shown a
correlation between reflux and chest pain when cardiac is
ruled out.
 Obstructive sleep apnea – most people get mixed sleep, may
complain during the day of feeling fatigued, headaches,
recent weight gain, anxiety, & hypertension. Smoking and
hypothyroid are additional risk factors for sleep apnea.
 Papadakis, M., McPhee, S. (2013).
Management Plan
 Have patient follow medication plan as discussed
earlier.
 Review smoking cessation plan with patient.
 Discuss how appointment with Pulmonary went.
 Discuss lab work, new medication status, and pain
management for chest pain, & blood pressure control.
Works Cited
 Epocrates (2014). Athena health company. Retrieved
from http://www.epocrates.com.
 Papadakis, M.A., & McPhee, S. J. (2013). Current
medical diagnosis & treatment. (52nd ed.). New York,
NY: McGraw-Hill Companies, Inc.