Introduction 100 WORDS A systematized and precise assessment is a vital tool for a clinician to identify not only patients who are in unpredictable life threatening situations but also to recognize the initial signs of patient’s deterioration. (Tough, 2004) In order to accomplish a systematic and detailed assessment, a sound clinical judgment and a strong, clinical based decision making by the clinician should be done. (Croskerry, 2009) This will aid in formulating a pertinent diagnosis, which is the key in devising a safe and effective treatment plan for the patient. (Croskerry, 2009) This essay is a case study of a patient who experienced chest pain. The goal of this paper is to draw up a clinical diagnosis that would be based on a complete medical history, a systematic physical assessment, and the utilization of three significant diagnostic tests to rule out other diagnoses. Word Count 141 Presenting Complaint / General Appearance 500 WORDS Mr. Z is a 54-year-old Pacific islander male. Mr. Z was brought to the emergency department in the emergency department via ambulance. The initial treatment that was given was Aspirin 300mg P.O. Two puffs of GTN (Glyceryl Trinatrate) and four mg of IV morphine. Mr. Z called the ambulance because of sudden onset of pain when he was walking up the stairs, about 4 to 5 steps. Another episode of chest pain was felt two days ago while he was gardening but was relieved with rest; the pain lasted for about five min. The location of the
was awakened from her sleep by sharp left sided chest pain. The pain worsened with motion and
A 68 year old male presented to the emergency department at 0800 hours via ambulance after experiencing chest discomfort and intermittent palpitations since 0500 hours. Prior to presentation, the patient stated he
Mr. XXXX is a 44 years old Caucasian male, a general construction worker who works on a nearby highway for the bridge project, and checked in this urgent care center for complaining of chest pain and shortness of breath (SOB). The chest pain is constant dull and pressure like pain, and started 3 hours ago. The pain is located on the center of chest. He rates the pain 4 out of 10 on a pain scale 0 to 10 while resting. The pain gets worse and increases after eating. He experienced increased chest pain and SOB with simple walking from the parking lot to this office. The pain was not resolved with taking PO 365mg of Aspirin 2 hours ago and resting. He was diagnosed with hyperlipedemia 10 years ago. He is taking medication to manage his high cholesterol level. He denies past history of chest pain, hypertension, and coronary artery disease. He denies any history of heart surgery or cardio artery bypass surgery. He is anxious and fearful for his first chest and SOB. He smokes a half pack a day for past 20 years. He drinks one bottle of bear every evening with meals. He denies taking any herbal medication or illicit drugs. He has been a good appetite. He reported 20 lbs weight gain since his retirement from military. He has an irregular meal time and does not exercise as much as he used to do in the military.
Management of the acutely ill adult is a complex and perplexed procedure. It requires underpinning knowledge of the pathophysiology of the disease currently affecting the patient, as well as ensuring that professionals are equipped to deal with the development of a rapid deterioration. The National Institute for Clinical Excellence (2007) explain that patients are sometimes inadequately treated due to staff not acting in a sufficient time manner, and so a systematic assessment of the patient recommended by the Resuscitation Council (2006) should initially be followed (Jevon, 2009).
Through basic observations, health professionals are able to evaluate the performance of an individual’s health status. In relation to Casey, it is noted in her Observation Chart that in the time span of two hours the patient’s health status had changed from being relatively normal (to the patient) to an increased respiratory rate, heart rate and temperature as well as a decrease in blood pressure. It is also noted that the patient has a score of 8 in the pain scale (compared to the score of zero two hours previously), relating to the lower abdomen. Programs such as Between the Flags acknowledges the fact that the early recognition of deterioration of patients can reduce harm to patients through designing and implementing systems which provide a structural response in the event of a deteriorating patient, such as Rapid Response and Clinical Review. There are two phases involved in the rapid response, which includes the afferent phase and the efferent phase. The afferent phase focuses on the overall monitoring and recognising the deteriorating patient whereas
Thomas’ chief complaint was a persistent, crushing chest pain that radiates to his left arm, jaw, neck, and shoulder blade. He also described the pain as a squeezing sensation around his heart. The medical term for this patient’s chief complaint is angina pectoris. Angina pectoris is the medical term for the chest pain or discomfort due to coronary heart disease.
Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.
There are also symptoms that involve the chest. These involve chest pain due to pleurisy, and irritation of the membranes lining the inside of the chest around the lungs, and pain due to pericarditis, and inflammation of the sack surrounding the heart. With both of these conditions there is difficulty in breathing, pain, shortness of breath, or a rapid heartbeat.
As Jane was presenting with a symptom of a life threatening event it was important that treatment was immediate. Priority was initially made from assessment of the airways, breathing and circulation, level of consciousness and pain. Jane’s respirations on admission were recorded at a rate of 28 breaths per minute, she looked cyanosed. Jane’s other clinical observations recorded a heart rate of 105 beats per minute (sinus tachycardia), blood pressure (BP) of 140/85 and oxygen saturation (SPO2) on room air 87%. It is important to establish a base line so that the nurse is altered to sudden deterioration in the patient’s clinical condition. Jane’s PEWS score (Physiological Early Warning Score) was 4 and indicated a need for urgent medical attention (BTS 2006). Breathing was the most obvious issue and was the immediate priority.
Mr. Howard, a 57-year-old man, had a 3-month history of progressive typical anginal chest pain. He reported that the symptoms first occurred with heavy exertion and involved what he described as“heaviness” in his chest. The symptoms were promptly relieved with rest. Over the past weeks, he had been experiencing increasingly frequent episodes of chest pain and diaphoresis. The episodes had become more prolonged, and he had experienced one episode of pain occurring at rest after a heavy meal. Mr. Howard was moderately obese and had a 20-year history of hypertension, which was being treated. Other risk factors in Mr. Howard’s history include hypercholesterolemia (350 mg/dL), which he was attempting to treat with dietary modifications, and a 30-year two-pack-a-day smoking history which continued up to the present time. Mr. Howard previously had surgery for a bilateral inguinal hernia repair, cholecystectomy, and arthroscopic surgery on his left knew. He also gave a history of problems with gastric reflux and was currently taking cimetidine (Tagamet).
Jim presented to Camberra Hospital almost one months ago with symptoms of right-sided anterolateral chest pain lasting a couple of days, a dry cough and breathlessness.
During my rotation there I observed patients coming in with chest pain and abdominal pain. The patients with chest pain had an
On Tuesday August 30, 2016 a Male 63 years of age came into Christus Spohn South Heath Center with a diagnostic order for chest and rib x-rays. He was being seen because of chest pain on his right side due to a fall. He had an extensive patient history of x-rays that went as far back as 2014. For the year of 2016 he received approximately 12 different x-ray series. For example, on January 12, 2016 he received a chest 1 view image and cardiac catheterization. On May 21, 2016 he received a chest 1 view and a complete 4 view foot. On May 30, 2016 he received a cardiac catheterization. On June 1, 2016 and again on June 2, 2016 he received a chest 1 view. On June 10, 2016 he received a catheterization. On August 25, 2016 he received a chest 2 view. On August 26, 2006 an upper extremity without contrast. The patient also has a history of open heart surgery and receives dialysis treatments and is on oxygen.
More recently, early warning systems have been developed in an effort to recognise the at-risk patient who may be deteriorating
Patient is a 45 yo male; 5’7”, 221 lbs who entered the emergency room at 6:30 am on 9/7/14 with severe chest pain (onset at 6:00 am) radiating to his arm, L arm numbness and nausea and vomiting. Past medical history reported by wife includes peptic ulcer, tobacco use (1-2ppd for 27 years), elevated blood pressure (controlled by lopressor). Wife did not know of any family history but reports patient’s father is deceased, died at 42 in his sleep. Mother alive and with high blood pressure.