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Running head: N439A DXR CASE 1
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DXR Case 1
Sojung Suk
University of California, Los Angeles
School of Nursing
N439A
January 25, 2012
Dr. Elizabeth Thomas
N439A DXR CASE 1
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SUBJECTIVE DATA
A. ID Data
Name: CD
Age: 47
Gender: Male
Race/ethnicity: AfricanAmerican
Marital status: Divorced
Children: None
NP visit date: 1/25/2012
PMD visit date: Haven’t seen
HCP for several years.
Address: house in Council
Bluffs
Occupation: High school
football coach and history
teacher
Insurance: HMO from job
Religion: Baptist
Advance Directive: No
information provided
Information source: Selfreliable
B. Chief Complaint: Racing heartbeat x 1month
C. HPI
1. Type: Racing heart beat
2. Location: Heart
3. Time: Experiencing racing heartbeat for 1 month, happens anytime, 2-3 times
during the day and once it happens it lasts for 20-30 minutes.
4. Associated factors: Denies ongoing medical diagnosis associated. Increased
caffeine intake. Recently started taking diet pill, Dexatrim to lose weight, No
recent health problem/infection/injury/insect bite/animal contact related. New
onset of symptom (no hx of racing heart beat). Denies (HTN, DM, CA, CAD,
CVA, ETOH abuse), Pt is overweight for years. His symptoms are like feeling
shaky,sweaty,dizzy and short of breath. When pt experienced the racing
heartbeat, pt felt anxious, scary, and made him afraid of doing anything
strenuous. He can’t walk as far as he used to and feeling tired very easily. No
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family member of any friends had similar problem. Ever since the symptom
started pt noticed that he takes slower pace in his activity.
5. Influencing factors: None. Also didn’t notice a pattern to it.
6. Treatment: None. (pt did not seek HCP for this symptom before)
D. Past Medical History
o Allergy: NKDA, + hay fever (seasonal allergy)
o Substances: Denies history of illicit drug and smoking. Pt drinks 2-3 beers a day.
o Preventives: Up to date with childhood immunization and other immunization
record due to work requirement. Received Tetanus booster couple yrs ago. Not
mentioned about (TDaP vaccines, pneumo vaccine, Hep A, MMR, Varicella
vaccine, Zoster vaccine, and Meningococcal vaccine).
o Trauma: cartilage repaired on left knee while a senior in college – Blood
transfusion history.
o Illness: Denies history of CAD, MI, CVA, HTN, CA, or any other illnesses.
o Medication: Datril 3-4 for knee 2-3 times a day, Dexatrim 2 tabs QD. OTC
(Laxatives, aspirin, cold preparations)
o Mental Health: Denies history of mental illnesses/hospitalization/counseling
history/ emotional problem.
o Environmental: Family visit to Chicago every summer went to Canada to fish last
year.
o Family History: 66 years old mother borderline diabetes due to overweight still
alive, father died with no apparent reason (keeled over and died one day) at age
62yrs old. Grandfather was an alcoholic. Pt has 4 brothers and all of them healthy
but most of them are overweight. (may have problem with high blood pressure but
N439A DXR CASE 1
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not taking medication) Denies family history of (CA,CAD,CVA, MI,
neuropsychological disorder, birth defects, kidney disease, cystic fibrosis, sickle
cell, asthma)
o Psychosocial History: Caffeine intake (have 3 cups of coffee in the morning and
3-4 Pepsi's during the day) Since pt got divorce, he eats out frequently, usually
skips breakfast, Burger King for lunch and have a double Whopper with fries. For
dinner, pt takes microwavable frozen dinner." Stressor( divorced couple years
ago), Exercise (lifting weights for past 2 months, used to be very active, playing
football in high school and college but pt knees are getting worse since few years
ago so running causes knee pain.) support system(lives alone, family lives in
Chicago but have very close relationship with family), coping mechanism( eating
fast food/drinking beer at night and watch TV), values( new girlfriend pt met
couple months ago/goes to church on Sunday/ friends), pt is baptist, education
history (graduated University of Iowa and majored in sports and minored in
world history." ), financial barrier (doesn’t make a lot of money as a teacher but
has medical insurance through job and since the coverage changed to PPO pt
visited the clinic ), occupation history(same job for 25 years old)
Review of System(ROS)
o General: -decreased appetite, +fatigue/+malaise (since last year), - insomnia, weakness, - night sweats or chills, and gained weight for past few years but lost 5
lbs with diet pills recently.
o Skin: Denies (pigmentation changes, rash, lesions, pallor, itching, pressure ulcers,
bruises, mole, and jaundice)
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o Head: Denies (head trauma, headache, dizziness, tenderness, lumps, masses,
history of seizure)
o Eyes: Denies ( wearing glasses, blind spots, glaucoma, inflammation, discharge,
blurred vision, photophobia, scotomato), + redness, + vision changes(bifocals
recently) last eye exam/treatment (last date: unknown)
o Ears: Denies (hearing changes, ringing in the ears, vertigo, earaches) last hearing
exam/treatment (unknown).
o Nose: Denies (nasal discharge, nose bleeding, nosebleeds, obstruction) +
congestion and +runny nose (when hay fever acts up)
o Mouth: Denies (sore throat, problems with teeth or gums, hoarseness, difficulty
swallowing)
o Neck: Denies (pain, decreased ROM, masses, goiter, swollen glands)
o Lymphatic: - enlarged lymph nodes or tenderness
o Respiratory: Denies (Cough, asthma, sputum, pulmonary embolism, and
wheezing), + SOB (after walking football field), Last TB/PPD-unknown.
o CVS: Denies (chest pain, murmur, orthopnea, paroxysmal nocturnal dyspnea,
dyspnea on exertion, edema, leg pain, cramps, varicose vein) Last EKG date: Dec
2010(result: normal) +palpitation, +fast irregular heart beat (arrhythmia)
o Endocrine: Denies (sweating, changes in hair, skin texture or growth, enlarged
thyroid, skin texture or growth, changes in glove/shoes sizes, polyphagia,
polydipsia, polyuria, heat/cold intolerance)
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o Musculoskeletal: +knee pain (left knee cartilage problem), +knee stiffness (makes
creaking sounds), Denies (swelling, soreness, inflammation, bone diseases,
muscle tenderness, muscle weakness). Last x-ray: several years ago.
o GI: Denies (sudden bowel incontinence, nausea, diarrhea, constipation, urgency,
change of pattern of bowel movements, abdominal pain, hemorrhoid, vomit,
hematochezia, dysphagia, hematemesis, hernia, melena, heartburn). Occult blood
test (unknown), colonoscopy (unknown)
o GU: Denies (sudden urinary incontinence, dysuria, frequency of urination,
urgency, and hematuria). BPH exam (unknown) Last self-testicular exam
unknown.
o GYN:N/A
o Hematology: Denies (frequent bruises, transfusion, coagulopathy, and anemia).
o Neurological: denies (Tingling, burning vertigo, numbness, abnormal sensations,
involuntary movements, ataxia, tremors, vertigo, dizziness, loss of consciousness,
seizures, epilepsy, memory loss, and strokes) Right handed, Last MRI testunknown.
o Psychiatric: Denies (illness, tension, unusual thoughts and loss of appetite,
paranoia, phobias, violence of tendencies, insomnia, sexual dysfunction, loss of
interest in activity, psychomotor retardation) Sexually active since couple months
ago and uses condom. +anxious (when experiencing racing heart beat)
II. OBJECTIVE DATA
A. Vital signs: Date-January 25, 2012
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Temp: 98.6, Pulse: 60, RR:16, BP:144/92, Wt:250 lbs, Ht: 5’9’’, BMI:36.91, O2
Sat: 97%, Heart Rate: 60
B. Labs & Test
CBC
WBC 6,000/cmm
RBC 5.10 m/cmm
Hemoglobin 15 g/dL
Hematocrit
49%
MCV 82 fL
MCH 29 µµg
MCHC 34%
Platelets
275,000/cmm
Bands 5%
Neutrophils 40% (low)
Lymphocytes 32%
Eosinophils 4%
Monocytes
6%
Basophils
1%
TSH
T4
2.7
7.6
EKG Normal sinus rhythm,
consisting of a P wave, QRS
complex and T wave. Normal
PR rate and rhythm.
Chest X-ray Normal
posterior-anterior and lateral
chest radiograph; Pulmonary
markings, cardiac size; pleura
C. Geriatric assessment:
1) MMSE – Not applicable / No information provided
2) GDS – Not applicable / No information provided
3) IADL – Not applicable / No information provided
4) ADL – Not applicable / No information provided
and soft tissue structures, and
proper invasive line
positioning.
CMP
Albumin
5.1
Alkaline phosphatase 73
ALT 38
AST 33
Bilirubin
0.73
BUN 12
Calcium
9.4
Carbon dioxide
29.3
Chloride
102.3
Creatinine
1.0
Glucose, random
120
Potassium
4.4
Sodium
142
Total protein 7.2
Cholesterol 225 mg/dL
(borderline high)
VLDL 25 mg/dL
LDL 162 mg/dL (high)
HDL 25 mg/dL (low)
Triglycerides 200 mg/dL
(high)
N439A DXR CASE 1
5) Tinetti Gait/Balance – Not applicable / No information provided
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6) Caregiver burden – Not applicable / No information provided
D. Physical Examination
1. General appearance: Well developed obese African American male in no distress, Awake,
alert, Oriented to time and place, appropriate mood and affect, calm, maintain eye-contact,
cooperative, answers appropriately.
2. Skin: Warm and dry, good skin turgor, no lesions noted.
3. HEENT:
Head- Hair distribution is full; hair is thick, with good luster, scalp is smooth and supple; no
lumps, interruptions, or other lesions are noted; the size and contour are normal, without
apparent deformities, and no areas of tenderness.
Eye- Symmetric in size, shape, color and position. No scars or growths are noted on lid or
conjunctiva. Cornea is clear; pupil is round, equal and black. Conjunctiva is moist and
without discharge, slight erythema noticed. Fundoscopy (performed: Disc margins are sharp
with medial choroidal crescents and a small visible cup is noted in the center of the disc; its
diameter is about one-third that of the disc, the disc is yellowish-pink and lighter in color
than the rest of the fundus, which is pinkish. Arterioles are bright red with a narrow light
reflex and there is no tapering or nicking noted where arteries cross veins. The fovea is shiny,
slightly darker pink, and there are no hemorrhages or exudates.)
Ears- Auricles are symmetric, normally placed, and without deformities; no area of
tenderness is noted. No ear lobe creases are present.
Mouth/teeth/throat- no toothache,
twenty-six teeth are present, several in both jaws having filled cavities, and no active caries
are noted; teeth are well-aligned and occlusion is symmetric with slight overbite. Gums are
pale red and meet enamel margins of the teeth. Lips are full, moist and without ulcers or
cracking. Buccal mucosa is pink, moist, and without ulcers or nodules. Hard palate is midline
N439A DXR CASE 1
and moves symmetrically. Tongue is full, pink, with normal papillae and without coating.
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Pharynx is diffusely pink with no exudate; tonsils are small and also without exudate.
Neck- Symmetric, no masses or scars. Hyoid bone, thyroid, cricoid cartilages and trachea are
symmetric, in the midline and mobile. Internal jugular pulses are noted to 2 cm. above the
sternal angle. On swallowing water the trachea rises well, -carotid bruit.
4. CVS: The chest is symmetric. On palpation at second right interspace (aortic), no thrill or
abnormal impulse is noted. On palpation at second left interspace (pulmonic), no thrill or
abnormal impulse is noted. On palpation at left 3rd, 4th, and 5th interspaces near the sternum
(tricuspid), no thrill or abnormal impulse is noted. The left ventricular impulse is lightly
palpable and visible in the left fifth intercostal space at the midclavicular line (mitral); it lasts
less than half of systole, has a tapping quality and occupies an area about 1 cm. in diameter.
No heave or thrill is palpable in the precordium. The right ventricle is not palpable.
Aortic: The first heart sound is single and normal in intensity. S2 is unremarkable. No
murmurs are heard in systole or diastole with the patient seated, supine, or in the left lateral
position.
Pulmonic: The first heart sound is single and normal in intensity. The splitting of S2
increases with inspiration and decreases with expiration. No murmurs are heard in systole or
diastole with the patient seated, supine, or in the left lateral position.
Tricuspid: The first heart sound is single and normal in intensity. S2 is unremarkable. No
murmurs are heard in systole or diastole with the patient seated, supine, or in the left lateral
position.
Mitral: The first heart sound is single and normal in intensity. S2 is unremarkable. No
murmurs are heard in systole or diastole with the patient seated, supine, or in the left lateral
position.Lungs: Respiration even and regular, lung sounds are clear bilaterally, low-pitched,
N439A DXR CASE 1
and of soft intensity, egophony (not performed), no lag with chest expansion. No
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adventitious sounds are audible.
5.
Lungs: The ratio of AP to lateral diameter is about 1:2. Respiratory movements are full,
symmetric, and without retractions; there is no paradoxic movement on expiration; breathing
is regular at 16 per minute, without apparent effort or use of accessory muscles. There is no
tenderness of the sternum, ribs or costochondral joints.
The spine is symmetric; there is lumbar lordosis and thoracic kyphosis; the iliac crests are at
equal height from the floor. Cervical spine is lordotic and symmetric. Chest expansion 2 cm.
Diaphragmatic excursion is 6 cm by percussion and is symmetric. Percussion of the
costovertebral angle did not elicit any discomfort bilaterally.
Lung sounds clear to auscultation all throughout with no adventitious sounds.
6. Abd/Rectum: bowel sounds positive to all quadrants, tympany percussed throughout, soft
and nontender abdomen, liver span assessed, -(bruit, pulsation), -CVS tenderness. –(Liver
mass, other abdominal mass). Guaiac: no information. The gallbladder is not palpable. The
liver edge is palpable on deep inspiration. There is no referred pain or rebound tenderness.
7. MS: Bilateral upper/lower extremities strong, ROM intact, (heel gate, toe gate; able to
accomplish without difficulties), straight leg test(able to perform without difficulty).
Trendelenberg Test/ patrickt’s test (not performed), Homan sign (not performed) ,– scoliosis.
8. Lymphatics: no lymph node enlargement noted.
9. Neuro: CN 2-12 intact, + DTR, Sensory intact from L4-L5 & S1, + motor vibration test,
Romberg Test (normal), - Babinski
E. Anderson’s Model: N/A
III.
ASSESSMENT
A. Palpitations
a) r/o Excessive caffeine intake
b) r/o Panic disorder
N439A DXR CASE 1
c) r/o Atrial fibrillation
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B. Obesity
C. Hypertension
D. Chronic pain on right and left knees
E. Health care maintenance deficit
IV.
PLAN
A1. Palpitations r/o excessive caffeine intake
a.
DX: Auscultation of heart sounds (aortic, pulmonic, tricuspid, mitral);
EKG for baseline; Holter monitoring if abnormal heart sounds and abnormal EKG
b. TX:
-
Reduce caffeine intake. Start by decreasing number of cups of coffee to one cup in the morning
and by decreasing number of Pepsi’s in a day by two on the first two weeks. To an occasional
cup of coffee or Pepsi the week after that.
-
Start regular physical activity.
c. Edu:
-
Educate about the effects of caffeine by stimulating the central nervous system causing increased
heart rate and palpitations.
-
Educate about benefits of regular physical activity in staying awake and alert. Some physical
activity is better than no physical activity. Encourage to start slow and gradually increase
duration and intensity as tolerated.
-
Assure patient that symptoms may go away when caffeine intake is reduced.
-
Advise patient to seek emergency medical care if there are episodes of chest pain, syncope, or
shortness of breath.
-
Follow up in two weeks to see if decreased caffeine intake helped lessen symptoms.
A2. Palpitations r/o Anxiety and panic disorder
a. DX:
Auscultation of heart sounds (aortic, pulmonic, tricuspid, mitral);
N439A DXR CASE 1
EKG for baseline; Holter monitoring if abnormal heart sounds and abnormal EKG
Psychosocial history, clinical interview
Generalized Anxiety Disorder 7-item (GAD-7) scale
b. TX:
Refer for cognitive behavior therapy
c.
Education:
-
Educate patient that medical symptoms are not life threatening and uncommon. Inform the
patient that in almost all cases the physical sensations that characterize panic attacks are not
acutely dangerous and will abate
-
Promote healthy behaviors such as exercise, good sleep hygiene, and decreased use of caffeine,
tobacco, alcohol, and other potentially deleterious substances.
-
Seek medical care right away if patient has thoughts of wanting to hurt self or others or if there
are episodes of chest pain, syncope, or shortness of breath.
A3. Palpitations r/o Atrial fibrillation
a. DX:
Auscultation of heart sounds (aortic, pulmonic, tricuspid, mitral); EKG; TSH
Holter monitoring if abnormal heart sounds and abnormal EKG; echocardiogram
b. TX:
-
Observation (pt is low risk, and palpitations resolving to SR spontaneously)
c. Education:
-
Avoid triggers such as alcohol, stimulants, caffeine, or nicotine to help prevent recurrence.
-
Advise patient to seek emergency medical care if there are episodes of chest pain, syncope, or
shortness of breath.
-
Follow up in six months for repeat echocardiogram.
B. Obesity
a.
DX: BMI
6
N439A DXR CASE 1
b.
TX: D/C Dexatrim. Refer to a weight loss program (Weight Watchers) that includes education on
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diet planning and exercise regimen
c.
Education:
-
Educate about the health benefits of weight loss: less pain on knees, decreased work for the heart
and lungs, decreased fatigue, and increased energy levels
-
Advise to avoid fast food. Refer to a diet planning class that helps in planning meals that are
quick and easy to prepare. Encourage to eat small frequent meals and not to skip breakfast.
Advise patient about increased risk for DM d/t mother’s current Hx of borderline DM.
-
Educate the patient that diet and exercise in combination is a proven to effectively reduce weight.
B. Hypertension
a.
DX: Blood pressure – standing and supine
b.
TX: Decrease caffeine intake, increased physical activity
Refer to dietician to help prepare meals that are low sodium
d.
Education:
-
Educate about the benefits of weight loss and modified diet to blood pressure
-
RTC after 3 months to recheck BP, along with weight, BMI, lipid panel
D. Chronic pain of left and right knees
a.
DX: X-ray of the left and right knee
b.
TX: Encourage patient to lose weight.
Continue on Datril as needed for pain management
e.
Education:
-
Educate about how weight loss may help relieve pain due to the additional pressure being placed
on the knees. Some physical activity is better than no physical activity. Encourage to start slow
and gradually increase duration and intensity as tolerated.
E. Health care maintenance deficit
N439A DXR CASE 1
a.
DX: For baseline – CBC, CMP, blood pressure, random glucose, cholesterol, cholesterol, LDL,
triglycerides,
b.
c.
TX:
-
Refer to RD to initiate Therapeutic Lifestyle Changes (TLC) program d/t abrnomal lipid panel.
-
Decrease ETOH consumption to 2 drinks per day of 12-oz beer.
Edu:
-
Educate about increased risk for heart disease due to abnormal lipid levels. Encourage weight
loss through diet low in fat and high in fiber, establishing a regular physical activity regimen.
-
RTC after three months to recheck weight, BMI, and lipid panel.
- Problem List:
Dx date
1/25/2012
1/25/2012
1/25/2012
1/25/2010
1/25/2012
Diagnosis
Obesity
Palpitation
Hyperlipidemia
Arthritis (knees)
Active/ Inactive
Active
Active
Active
Active
HTN
Active
Differential Diagnosis: Palpitations
Dx
Excessive caffeine
intake
Pertinent Positives
Pertinent Negatives
(+) palpitations
(+) current use of caffeine
(+) no pattern
(+) happens anytime during the day
Anxiety and panic
disorder
(+) sweaty, shaky, anxious with
episodes of palpitations
(+) unexpected onset
(+) worry
(+) tachycardia
(-) chest pain and discomfort
(-) nausea and abdominal pain
(-) perceptual abnormality
(-) behavioral avoidance
(-) reliance on safety cues
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N439A DXR CASE 1
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(+) palpitations
(-) paresthesias
(+) dizziness
(-) fainting
(+) respiratory symptoms
(-) chills or hot flushes
Atrial fibrillation
(+) palpitations
(-) irregular pulse rate
*Red flag*
(+) dizziness
(-) hyperthyroidism
(+) SOB
(-) hypotension
(+) episodes lasting minutes to
hours
(-) added heart sounds
(-) rales
(-) evidence of stroke
Wolff-Parkinson-White
syndrome (WPW)
*Red flag*
(+) palpitations
(-) chest pain
(+) dizziness
(-) atrial fibrillation
(+) SOB
(-) atrial flutter
(-) syncope and presyncope
(-) tachycardia in pregnancy
(-) congenital cardiac abnormalities
Long QT syndrome
(+) palpitations
(-) hx of known gene mutation
*Long QT syndrome*
(+) dizziness
(-) use of drugs or circumstances known to
increase the QT interval
(+) fatigue
(+) FHx of sudden death
(-) syncope during heightened adrenergic
tones
(-) syncope during arousal or surprise
(-) syncope at rest and during bradycardia
(-) cardiac syncope
(-) periodic paralysis
(-) dysmorphic features
(-) sensorineural deafness
(-)angina
(-) oliguria
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(-) muscle weakness
(-) tetany
(-) numbness
(-) Chvostek's sign
(-) Trousseau's sign
(-) cold and pale extremities
(-) hypotension
(-) confusion
Hypertrophic
cardiomyopathy
*Red flag*
(+) palpitations
(-) FHx of HCM
(+) FHx of sudden death
(-) hx of presyncope or syncope
(+) younger male (<50 years)
(-) left ventricular lift
(+) dyspnea
(-) double apical impulse or double carotid
pulsation
(-) angina
(-) irregularly irregular pulse
(-) older female (>50 years)
(-) collapse
(-) fourth heart sound
Hyperthyroidism
(+) palpitations
(-) recent weight loss
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References
American Psychological Association. (2010). Publication manual of the American
Psychological Association (6th ed.). Washington, D.C.: Author.
National Guideline Clearinghouse (NGC). Guideline summary: Lipid management in adults. In:
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Healthcare Research and Quality (AHRQ); [cited 2012 Jan 23]. Available:
http://www.guideline.gov.
National Guideline Clearinghouse (NGC). Guideline summary: Practice guideline for the
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N439A DXR CASE 1
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