SUBJECTIVE:
Samuel, a 48 – year – old male, presents to the office with mild – to – moderate chest pressure with radiation to his back. Samuel reports that he was awakened from sleep at 7:00 a.m. with chest pressure, initially described as soreness across his anterior chest and through to his back. He rates his pain + 6/10. He felt as though, if he could just belch, he would feel better. His wife drove him to the office to be here when it opened at 9:00 a.m. She tried to convince Samuel to go to the emergency room; but he emphatically refused, insisting on going to the office first. Upon arrival at the office, you take Samuel back to an examination room and instruct the receptionist to call 911.
Past medical/surgical history: Diabetes mellitus type 2.
Family history: He has a family history of premature coronary artery disease. His father died of acute myocardial infarction ( AMI ) at age 45. One brother died of AMI at age 49. Social history: He has smoked for 25 years but has reduced his smoking to 1 pack per day since his brother’s death two years ago. He has put on 25 pounds in the past two years and is generally sedentary.
Medications: Samuel was diagnosed with type 2 diabetes last year. He has been fairly well controlled with diet and Metformin, 500 mg daily. His last hemoglobin A1C was 7.4 two months ago.
Allergies: Latex.
OBJECTIVE
General: He is anxious and showing signs of chest pain as you enter the office room. He is slightly diaphoretic. He took an oral aspirin on the way to the office.
Vital s signs: BP: 192/96; P: 102; R: 22; T: 97.8. His SpO2 is 90%.
ECG: His stat ECG shows ST segment depression and T wave inversion in leads II and III.
Cardiovascular: His heart tones are muffled with an S3 gallop. His hands and feet are cool to touch. Radial pulses are 2 +. Pedal and posterior tibial pulses are 1 +. He has neck vein distention of 5 cm with the head of the bed at 90 degrees. He has no carotid bruits, heaves, or thrusts. His PMI is at the 5th ICS, left mid-clavicular line.
Respiratory: He has harsh rhonchi in the upper lobes bilaterally and a nonproductive cough.
- Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Explain (One paragraph)
- What is the most likely differential diagnosis and why? (One paragraph)
- Explain the treatment plan (One paragraph)
a. What referrals are needed? Explain
- Does the patient’s family history impact how you treat this patient? (One paragraph)
- What are the primary health education issues? Explain (One paragraph)
- Are there any standardized guidelines you should use to assess/treat this case? Explain (One paragraph)
