Part One: Initial Patient Evaluation
Patient Overview:- Name: Sean M.
- Age: 52 years old
- Ethnicity: White male
- Medical History: History of hypertension (HTN), previously taken off HTN medications at the last visit almost 3 months ago.
- Chief Complaint: Sean presents to the clinic following an episode of chest pain three days ago.
- Chest Pain and Associated Symptoms:
- Can you describe the chest pain in more detail? Was it sharp, dull, or pressure-like?
- Did the chest pain radiate to your arms, back, neck, or jaw?
- Did you experience any 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?
- Activity and Triggers:
- 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?
- Current Health and Lifestyle:
- Have you noticed any changes in your energy levels or increased fatigue recently?
- Have you resumed your workout routine since the episode? If so, how did you feel?
- Do you monitor your blood pressure regularly? If yes, what have your recent readings been?
- Past Medical History and Risk Factors:
- Have you ever experienced similar symptoms in the past, even if they were milder?
- Have you ever been diagnosed with any other heart-related conditions?
- Do you have any history of high cholesterol, diabetes, or other conditions that might affect your heart health?
- Family History:
- You mentioned your brother died of melanoma at a young age—was there any history of cardiovascular disease in your family besides your father’s lung cancer and your mother’s stroke?
- 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?
- Angina Pectoris (I20.9): Sean’s chest pain, especially the heaviness and associated symptoms like shortness of breath, nausea, and sweating, could indicate angina, particularly if it was precipitated by physical activity or stress.
- Myocardial Infarction (MI) (I21.9): The episode of chest pain could be a warning sign of an acute coronary event. The ST depression on the EKG increases the suspicion of myocardial ischemia.
- Gastroesophageal Reflux Disease (GERD) (K21.9): GERD can mimic cardiac chest pain, presenting with a burning sensation, heaviness, and even nausea. Given that the pain was short-lived and hasn’t recurred, this could be a possibility.
- 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.
- 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.
- Cardiovascular System:
- Pertinent Positives: Evaluate for any signs of ischemia such as ST changes on EKG, auscultate for murmurs, S3/S4 gallops, and assess peripheral pulses.
- Pertinent Negatives: Absence of jugular venous distention (JVD), peripheral edema, or heart murmurs.
- Respiratory System:
- Pertinent Positives: Assess for wheezing, rales, or rhonchi, which could indicate cardiac or pulmonary etiology.
- Pertinent Negatives: Clear lung fields on auscultation, absence of respiratory distress.
- Gastrointestinal System:
- Pertinent Positives: Assess for epigastric tenderness, which could indicate GERD or other GI-related causes of chest pain.
- Pertinent Negatives: Absence of rebound tenderness or abdominal rigidity.
- Musculoskeletal System:
- Pertinent Positives: Palpate the chest wall for tenderness, which could suggest costochondritis.
- Pertinent Negatives: Lack of reproducible pain with palpation.
- 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
1. Based on JNC 8 guidelines, is Sean hypertensive? According to the JNC 8 guidelines, hypertension is defined as a systolic blood pressure (BP) of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher in the general population aged 60 years or younger. Although Sean’s specific BP readings during this visit are not provided, his history of hypertension, coupled with his presentation of chest pain, warrants a thorough assessment to determine if his BP is currently controlled or if he has had any recent hypertensive episodes. 2. In-office EKG shows ST depression. What are your diagnoses with ICD-10 codes for Sean? Include the rationale and a reference for your diagnoses. Diagnoses:- Unstable Angina (I20.0): ST depression on the EKG suggests myocardial ischemia, which is consistent with unstable angina. This condition is characterized by chest pain that occurs at rest or with minimal exertion and can be a precursor to myocardial infarction.
- 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.
- Hyperlipidemia, Unspecified (E78.5): Sean has a history of hyperlipidemia, which is a significant risk factor for coronary artery disease and contributes to his cardiovascular risk profile.
- 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.
This comprehensive response outlines the necessary questions, differential diagnoses, physical examination, diagnostic testing, and management plan for Sean M., integrating evidence-based guidelines and clinical reasoning. The inclusion of ICD-10 codes and detailed planning reflects the appropriate level of care needed for a patient presenting with cardiovascular concerns.
