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Running head: N439A DXR CASE 1 1 DXR Case 1 Sojung Suk University of California, Los Angeles School of Nursing N439A January 25, 2012 Dr. Elizabeth Thomas N439A DXR CASE 1 2 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 N439A DXR CASE 1 2 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 3 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) N439A DXR CASE 1 4 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) N439A DXR CASE 1 5 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 N439A DXR CASE 1 6 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 2 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. 3 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 4 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 5 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 7 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 8 N439A DXR CASE 1 9 (+) 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 N439A DXR CASE 1 10 (-) 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 N439A DXR CASE 1 2 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: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [cited 2012 Jan 23]. Available: http://www.guideline.gov. National Guideline Clearinghouse (NGC). Guideline summary: Practice guideline for the treatment of patients with panic disorder. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [cited 2012 Jan 21]. Available: http://www.guideline.gov. Sawchuck, C. N., & Veitengruber, J. P. Epocrates Online Diseases [Internet]. San Mateo (CA): Epocrates, Inc. c2011. Panic disorder; [updated 2011 Sep 01; cited 2012 Jan 24]. Available from: http://www.epocrates.com. Shah, A. N., & Kantharia, B. K. Epocrates Online Diseases [Internet]. San Mateo (CA): Epocrates, Inc. c2011. Atrial fibrillation; [updated 2011 Dec 30; cited 2012 Jan 24]. Available from: http://www.epocrates.com. Spitzer, R. L., Kroenke, K., Williams, J. B. W., Lowe, B. (2006) A brief measure for assessing generalized anxiety disorder. Archives of Internal Medicine. 166, 1092-1109. Retrieved from http://www.mpho.org/resource/d/34008/GAD708.19.08Cartwright.pdf Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care. St. Louis: Mosby. Epocrates (2011). Retrieved from https://online.epocrates.com/noFrame/ N439A DXR CASE 1 Pubmed health (2011). Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002240/ Seidel, H. M. (2011). Mosby's guide to physical examination. St. Louis, Mo: Mosby/Elsevier. 3