You will take on the role of a clinician who is building a health history…
Chief Complaint (CC) – A 75-year-old female reports experiencing pain in her chest while walking up steps today.
Subjective- Could not sleep previous night. Feels like an ache or a burning sensation at the center of sternum. Denies any arm pain, pain was at a scale of 8 in the AM now it is at a 2. Suffers from History of hypertension, denies heart disease, denies leg swelling up, denies pain feeling worse when taking deep breath. It feels like there is a pain or a burning in the middle of the sternum. Denies having any arm pain. The pain was an 8 in the morning and is now a 2. Has a history of high blood pressure, but says he doesn’t have heart disease, that his legs don’t swell up, and that his pain doesn’t get worse when he takes deep breaths.
Objective Data
VS- BP 129/70, (HR) 72 and regular, (RR) 16 unlabored, temperature 98.8°F, oral pulse oximetry is 99%
General- obese female, alert, in no acute distress.
HEENT- Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.
Respiratory- CTA AP&L
Neck/Throat- carotids are 2+ without bruits; thyroid is not palpable; no lymphadenopathy.
Heart- S1 and S2 normal without murmur, gallop, or rub
Answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms?
5. Give rationales for your each differential diagnosis.
Post should be at least 500 words, formatted and cited in current Help write my thesis – APA style with support from at least 2 academic sources.
