Posted: July 9th, 2022

A 58-year-old male presents with a complaint of severe chest pain

Select one of the following cases to discuss. In the subject line of your post, please identify which prompt you are responding to, for example, choice #2 19-year old male.
Case 1: An 89-year-old female complains of a “stabbing chest pain” and points to the area just below her scapula at the right mid-clavicular line. She states that she had an upper respiratory infection last week that “just seems to hang on.” No other complaints.
Case 2: A 58-year-old male presents with a complaint of severe chest pain over the last hour. He states that he did not call 911 because he cannot afford an ambulance.
Case 3: A 15-year-old immigrant was brought to the clinic by her mother because patient complains of shortness of breath, chest pains, diaphoresis and easy fatiguability. She claims she has had on and off bouts of tonsillitis since she was a child that resulted in tonsillectomy surgery when she was 12. Last week, she was unable to participate in the cheer leading tryouts because of knee pain and a rash that she noticed on her trunk for the past 2 weeks.
For the case you have chosen, post to the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
-Pertinent positive findings that validate your main diagnosis
-Pertinent negative findings that make you think of other differential diagnoses
-Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
Initial post must have a minimum of 300 words, excluding references.
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Case 2: A 58-year-old male presents with a complaint of severe chest pain over the last hour. He states that he did not call 911 because he cannot afford an ambulance.

Questions I would ask the patient:

Could you describe the chest pain to me in more detail? Is it sharp, dull, crushing, aching, or something else?
On a scale of 0-10, how severe is the pain?
Have you ever had a similar pain before? If so, when and under what circumstances did it occur?
Have you had any other symptoms in addition to the chest pain, such as shortness of breath, nausea, vomiting, dizziness, or sweating?
Do you have a history of heart disease or any other medical conditions?
Are you currently taking any medications?
Physical exam elements I would include:

Vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation
Heart sounds, including rate and rhythm
Lung sounds
Examination of the abdomen
Palpation of the chest to assess for tenderness or swelling
Evaluation of the patient’s overall appearance and level of distress
Further testing I would want to have performed:

Electrocardiogram (ECG) to assess for any abnormalities in the heart’s electrical activity
Blood tests, such as a cardiac enzyme panel to check for markers of heart damage
Chest x-ray to assess for any abnormalities in the heart or lungs
In SOAP format:

Subjective: The patient is a 58-year-old male who presents with a complaint of severe chest pain that has been ongoing for the last hour. He reports that the pain is crushing in nature and rates it as an 8 out of 10 in severity. He has no other notable symptoms. The patient has a history of hypertension but denies any previous heart problems. He is currently taking lisinopril for his blood pressure.

Objective: Upon examination, the patient appears uncomfortable and is clutching his chest. His vital signs are within normal limits except for a slightly elevated heart rate of 100 beats per minute. Heart sounds are regular with no murmurs or gallops heard. Lung sounds are clear. The abdomen is soft and non-tender. There is mild tenderness upon palpation of the chest.

Assessment: Based on the patient’s history and physical exam, the most likely diagnosis is acute coronary syndrome (ACS). ACS is a term used to describe a range of conditions that occur when there is a sudden reduction or blockage of blood flow to the heart muscle, leading to chest pain and potentially other symptoms. The crushing chest pain and elevated heart rate are both consistent with ACS.

Plan: The patient will be started on aspirin and a nitroglycerin sublingual tablet to help improve blood flow to the heart and relieve the chest pain. He will also be given intravenous (IV) heparin to help prevent further clot formation. An ECG and blood tests will be ordered to confirm the diagnosis and assess for any damage to the heart. A chest x-ray will also be obtained to rule out any other potential causes of the chest pain. The patient will be advised to follow up with a cardiologist for further management and evaluation. In the meantime, he will be educated on the importance of lifestyle modifications, such as eating a healthy diet, getting regular exercise, and not smoking, to help reduce his risk of future cardiovascular events. The patient will also be referred to financial assistance programs to help cover the cost of his medical care.

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