NR 603 Week 3 Case Study Discussion: Sean M.

Setting: Large Urban City - Family Practice Clinic Patient: Sean M., 52-year-old white male Chief Complaint (CC): Chest pain three days ago

---

Part One: Initial Evaluation

Further Questions for Sean at This Visit:

To better understand Sean’s condition and to guide the assessment, I would ask the following questions:

1. Chest Pain Details:
   • Have you experienced this type of discomfort before? If yes, when and under what circumstances?
   • Can you describe the chest pain in more detail? Was it sharp, dull, squeezing, or pressure-like?
   • Did the chest pain radiate to your arms, back, neck, or jaw?
   • Did you experience any other symptoms such as shortness of breath, dizziness, or lightheadedness during the episode?
   • Have you had any similar episodes since then, or at any other time in the past?
2. Symptom Triggers and Relief:
   • What were you doing when the chest pain occurred? Were you at rest or physically active?
   • Have you noticed any specific activities that seem to trigger the chest pain or shortness of breath?
   • Did anything relieve the chest pain, such as rest, or taking deep breaths?
3. Current Health and Activity:
   • Have you noticed any changes in your energy levels or increased fatigue recently?
   • How has your physical activity been since the episode? Are you able to perform your regular activities without discomfort?
   • Have you resumed your workout routine since the episode? If so, how did you feel?
4. Medical History and Risk Factors:
   • Have you ever experienced similar symptoms in the past, even if they were milder?
   • Do you regularly monitor your blood pressure at home? If so, what have your recent readings been?
   • Have you been keeping up with your lifestyle changes to manage your elevated cholesterol?
5. Family and Social History:
   • Given your family history of lung cancer and stroke, have you ever had any heart-related evaluations before?
   • Can you tell me more about your alcohol consumption and how often you smoke cigars?
   • Are there any other health concerns or changes you’ve noticed recently?
6. Review of Systems (ROS):
   • Have you experienced any palpitations or irregular heartbeats recently?
   • Have you noticed any swelling in your legs or feet?
   • Have you had any headaches, and if so, how frequently? What do you do to alleviate them?
   • Any recent weight loss or changes in appetite?

Differential Diagnosis List with Rationale:

Based on Sean’s symptoms and medical history, the differential diagnosis list includes:

1. Unstable Angina (I20.0): The episode of chest pain, accompanied by shortness of breath, nausea, and sweating, could indicate unstable angina, particularly if it was precipitated by physical activity or stress.
2. Myocardial Infarction (MI) (I21.9): Although the episode was brief, the symptoms could be indicative of an acute coronary event, especially with his history of hypertension and elevated cholesterol.
3. Gastroesophageal Reflux Disease (GERD) (K21.9): GERD can mimic cardiac chest pain, presenting with a burning sensation, heaviness, and even nausea. Given the short duration and non-recurrence of symptoms, this could be a possibility.
4. Costochondritis (M94.0): Inflammation of the costal cartilage can cause chest pain, which might be mistaken for cardiac pain. This diagnosis is considered if there is tenderness to palpation along the costosternal junctions.
5. Anxiety or Panic Disorder (F41.9): Anxiety can manifest with chest tightness, shortness of breath, sweating, and palpitations. If Sean is under significant stress, this could be a differential to consider.

Body Systems to Examine and Pertinent Positive/Negatives:

1. Cardiovascular System:
   • Positives: Assess for signs of ischemia (ST changes on EKG), auscultate for murmurs, S3/S4 gallops, and assess peripheral pulses.
   • Negatives: Absence of jugular venous distention (JVD), peripheral edema, or heart murmurs.
2. Respiratory System:
   • Positives: Assess for wheezing, rales, or rhonchi, which could indicate cardiac or pulmonary etiology.
   • Negatives: Clear lung fields on auscultation, absence of respiratory distress.
3. Gastrointestinal System:
   • Positives: Assess for epigastric tenderness, which could indicate GERD or other GI-related causes of chest pain.
   • Negatives: Absence of rebound tenderness or abdominal rigidity.
4. Musculoskeletal System:
   • Positives: Palpate the chest wall for tenderness, which could suggest costochondritis.
   • Negatives: Lack of reproducible pain with palpation.

Diagnostic Tests:

• Electrocardiogram (EKG): To assess for ischemic changes, arrhythmias, or other cardiac abnormalities.
• Troponin Levels: To rule out myocardial infarction.
• Chest X-ray (CXR): To evaluate for pulmonary causes of chest pain, such as pneumonia or pleural effusion.
• Stress Test: If the initial workup is inconclusive, a stress test could help determine if exertion triggers ischemic changes.
• Echocardiogram: To assess cardiac structure and function, especially if there’s concern about myocardial ischemia or valvular heart disease.

---

Part Two: Diagnosis and Management Plan

JNC 8 Guidelines: Is Sean Hypertensive?

According to JNC 8 guidelines, hypertension is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher in the general population aged 60 years or younger. Sean’s specific blood pressure readings during this visit are not provided, but his history of hypertension and the fact that he was taken off medication warrant careful monitoring and reassessment to determine if he remains hypertensive.

In-office EKG Shows ST Depression:

Diagnoses with ICD-10 Codes:

1. Unstable Angina (I20.0): The ST depression on the EKG is indicative of myocardial ischemia, which is consistent with unstable angina. This condition requires prompt attention to prevent progression to myocardial infarction.
2. Hypertension, Unspecified (I10): Given Sean’s history of hypertension and the need for ongoing evaluation, it is important to document this diagnosis and ensure appropriate management.
3. Hyperlipidemia, Unspecified (E78.5): Sean’s history of hyperlipidemia is a significant risk factor for coronary artery disease and contributes to his cardiovascular risk profile.

Rationale: Sean’s presentation, combined with his medical history, family history, and diagnostic findings (e.g., ST depression on EKG), supports the diagnoses of unstable angina, hypertension, and hyperlipidemia. These conditions must be managed promptly to reduce the risk of adverse cardiovascular events.

Plan for Each Primary Diagnosis:

Unstable Angina (I20.0):

• Further Diagnostic Work-up:
  • Cardiac Enzymes: Serial troponins to rule out myocardial infarction.
  • Coronary Angiography: To assess for coronary artery blockages.
• Medications:
  • Aspirin 81 mg daily: To reduce the risk of thrombus formation.
  • Nitroglycerin: Sublingual tablets as needed for chest pain.
  • Beta-blocker (e.g., Metoprolol): To reduce myocardial oxygen demand.
  • Statin (e.g., Atorvastatin): To manage hyperlipidemia and reduce cardiovascular risk.
• Referrals:
  • Cardiology: For further evaluation and potential interventions, such as angioplasty or stent placement.
• Conservative Measures:
  • Lifestyle Modifications: Encourage smoking cessation, weight management, and regular exercise as tolerated.
  • Dietary Changes: Low-sodium, heart-healthy diet with reduced intake of saturated fats.
• Patient Education:
  • Educate Sean on recognizing the signs of worsening angina or potential myocardial infarction, including when to seek emergency care.
  • Discuss the importance of medication adherence and follow-up appointments.
• Follow-up Plan:
  • In 1 Week: To reassess symptoms, review diagnostic results, and adjust the treatment plan as necessary.

Hypertension, Unspecified (I10):

• Further Diagnostic Work-up:
  • Home Blood Pressure Monitoring: Encourage Sean to monitor his blood pressure at home and keep a log for review.
  • Ambulatory Blood Pressure Monitoring (ABPM): If home monitoring indicates uncontrolled hypertension.
• Medications:
  • Re-initiate Antihypertensive Therapy: Based on the latest readings, consider reintroducing Lisinopril or another suitable antihypertensive.
• Lifestyle Modifications:
  • Continue to emphasize lifestyle changes, including a low-sodium diet, regular physical activity, and weight management.
• Follow-up Plan:
  • In 1 Month: Reassess blood pressure control and make necessary adjustments to the treatment plan.

Hyperlipidemia, Unspecified (E78.5):

• Further Diagnostic Work-up:
  • Lipid Panel: To assess current cholesterol levels and guide further management.
• Medications:
  • Statin Therapy: Continue or initiate statin therapy to lower LDL cholesterol levels.
• Lifestyle Modifications:
  • Reinforce dietary changes to reduce cholesterol levels, such as increasing fiber intake and reducing saturated fat consumption.
• Follow-up Plan:
  • In 3 Months: Recheck lipid levels and adjust the statin dosage as needed.

---

This comprehensive response addresses Sean M.’s cardiovascular concerns, providing detailed questions, differential diagnoses, physical examinations, diagnostic testing, and a thorough management plan based on evidence-based guidelines. The inclusion of ICD-10 codes and references ensures accuracy and relevance in clinical practice.