Chief Complaint: A 42-year-old patient post op abdominal cholecystectomy. complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies.
A 42-year-old patient is 3 days post-op from abdominal cholecystectomy. She is currently taking only antibiotics and hydrocodone. Today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies. I would ask when did the pain began? I would ask what will make the pain worse ? I would ask the patient to describe what symptoms she has when she dorsiflexes the leg. I would ask if the pain radiates anywhere else. I would ask how often she goes for walks? I would ask if she has noticed any discoloration on left calf. I would ask If she wears any compression stockings post-surgery. I would ask what is how much pain medicine does she take in a day? I would ask if she has had any injuries to her calf ? I would ask if there are any open wounds in the left calf? Has she been able to walk on both legs?
Ears, Nose, Mouth, and Throat: Sore throat, slight cough no phlegm, difficulty hearing, reports no sinus issues
Neurological: Dizziness, stable gait, fatigued , no double vision, no tremors, reports no fainting
Cardiac: no chest pain, no significant weight gains recently
Respiratory: Shortness of breath, persistent cough not coughing up blood or any phlegm
GI: Heartburn, constipation, no diarrhea, no blood in stools, no nausea or vomiting, change in bowel habits
GU: Painful urination, recent UTI, burning urination, bladder issues
Skin: no rashes on the skin, skin pale in color
Musculoskeletal: left swollen left calf, unsteady gait does to pain on left calf
Psychiatric: no Depression, reports slight anxiety and sadness, no suicidal ideations,
O – Objective:
Patient Alert x4, calm and cooperative, able to speak full sentences,
I will be pulling this patient’s vital signs, I would pull patients physical exams, I would like to perform a physical inspection of Bilateral lower extremity , I would like to see both the limbs and check for symmetry, I would like to see unilateral swelling , skin changes, I would like to see if the patient had any varicose veins, I would like to check for heat with your hand above the suspected area of DVT before palpation, I would like to check for pulses on both legs, I would also check capillary refills, I would want to see if the patient could bare weight on BLE, I would order CBC, CMP, lactic level, , CK , D- Dimer, I would also order proximal leg vein ultrasound
Working Diagnosis – Popliteal Deep Vein Thrombosis
Pertinent positive: post op, abdominal surgery, today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch, (2020)
Pertinent negative- none
Differential Diagnosis: : Cellulitis of Left lower extremity
Pertinent positive- swelling and painful left calf, warm to touch
I would order PT/INR CBC, CMP, lactic level, , CK , D Dimer, I would also order proximal leg vein ultrasound, have an accurate weight on the patient, I would start patient on Lovenox Pharmacy to dose based on kidney panel and patients weight, Drug, (2021). I would like to have a follow up 2 weeks later to see the respond to the medication.
What were your strengths in this course? – My strengths would be gaining knowledge on assessment and how to stop looking superficially but diving in deep to assess a patient snd their symptoms.
What was challenging? – I think what was most challenging was coming up with working diagnosis/differential diagnosis and figuring out the pertinent negative/pertinent positives for these.
What new learning or insight was developed? – I believe the new insight would be the SOAP. It allows the nurse to organize her discovery and able to solve the puzzle.
What new clinical skills have you gained? – I gained how to become a better interviewer and digging deep to able to give us a clear image of what the patient is going through.
2. A 66-year old woman complains of shortness of breath, numbness and heaviness of her arms when walking up the hill to her house. The pain subsides when she stops to rest.
S – Subjective
CC – Patient stating “Whenever I walk up the hill to my house, I get short of breath and I feel my arms get numb and heavy. I also get chest pain when walking, but that pain goes away when I stop to rest.”
HPI – Patient is a 66-year old woman who complains of shortness of breath, numbness and heaviness of her arms when walking up the hill to her house. She states that there is chest pain which subsides when she stops to rest.
PMH – Some questions to ask this patient would include: Do you have a history of heart issues? Do your mother and father have/had heart issues? Do you take any medications for heart issues? Please describe the pain you are feeling in your chest. Does the pain radiate anywhere else in the body? How long does the pain last? Is there anything you do to treat the pain? Have you gone to the hospital or emergency department before for this thing in the past?
MEDS – Are you taking any medications currently? Do you take medications for heart issues? Do you take any medications for your pain?
Allergies – Are you allergic to any medications? Are you allergic to any foods? Are you allergic to anything in the environment such as dust, pollen, pet dander?
FH – Does anyone in your family have or had any heart issues issues? Has anyone in your family died of a heart attack? Does anyone in your family have issues with cholesterol?
Social history – Do you smoke cigarettes, if so how often? Do you smoke marijuana? Do you take recreational drugs? Do you drink alcohol, if so much and how often?
Health related behaviors – Do you exercise? Are you active in your lifestyle? Explain what you normally do for work. What do you do on your free time? What does your diet consist of? What do you normally eat?
Review of Systems:
Constitution/General – I would ask the patient how she is generally currently feeling. I would ask if she feels tired, unwell, or lethargic.
Neurological – I would ask her if she has any issues with double vision, issues with walking, issues with balance. I would ask if she has had dizziness or fainting spells.
Respiratory – I would ask her if she has current shortness of breath, if it hurts when she breathes in, if the chest pain hurts when breathing out. I would ask when she gets short of breath when walking up the hill how long it takes for her to catch her breath. I would ask if she uses oxygen at home.
Cardiac – I would ask her if she has any feelings of racing heart beat, skipping heart beat, feeling like she can faint, swelling of arms or legs, what her chest pain feels like and do an OLDCART assessment, and if anything that makes it feel better. I would ask about her lifestyle and what she does. I would ask if she has had previous chest pain like this in past.
Psychiatric – I would ask the patient about a history of depression, anxiety, feelings of worthlessness, suicidal ideations, hearing voices or thoughts of harming self or others.
O – Objective
I would obtain vital signs, numeric pain scale, oxygen saturation and temperature. I would obtain lab results such as a CBC, CMP, lipid panel, troponin, EKG, and order a cardiac stress test.
General – Patient is awake, alert, oriented to time, place, person, situation. Appropriate in speech and language, clear and logical. No acute distress noted.
Cardiac – S1 and S2 auscultated, no murmurs or gallops present, heart rate and rhythm WNL, pulses palpable BL all extremities +2. Patient skin warm to touch and normal turgor. BP = 143/89, HR = 98. Patient is obese BMI 35.
Respiratory – Chest wall is symmetric, atraumatic, lung sounds WNL in all quadrants, SpO2 98%.
Psychiatric – Patient is calm and cooperative, patient has good judgement and insight, denies suicidal or homicidal ideations.
A – Assessment
Working Diagnosis – Angina pectoris, unspecified – 2022 ICD-10-CM Diagnosis Code I20.9
Pertinent positive: Chest pain that subsides with rest. Chest pain that subsides with rest or medication (nitroglycerin) is a common symptom of stable angina (Sullivan, 2018).
Pertinent negative: Patient is obese and has high blood pressure. These are risk factors for having stable angina (Sullivan, 2018).
Differential Diagnosis – Acute ischemic heart disease, unspecified – 2022 ICD-10-CM Diagnosis Code I24.9
Pertinent negative: Sudden numbness and heaviness with shortness of breath are symptoms of an acute coronary event such as a myocardial infarction (Mayo Clinic, 2021).
Differential Diagnosis – Nonrheumatic aortic (valve) stenosis – 2022 ICD-10-CM Diagnosis Code I35.0
Pertinent negative: Shortness of breath when walking short distances, chest pain, fatigue on exertion are all signs and symptoms of aortic valve stenosis (American Heart Association, 2020).
P – Plan
The patient states she has chest pain on exertion. In order to make sure the patient isn’t having an active myocardial infarction an EKG will be done along with troponin. My working diagnosis is stable angina or angina pectoris due to the chest pain relief on rest. Since that is my working diagnosis I would still perform an EKG and also a stress test. A stress test may show EKG changes on exercise and will also show me if the patient gets symptomatic again with exercise (Sullivan, 2018). I also would like to order an ECHO as well to rule out aortic valve stenosis due to patient’s age at 66 years-old and similar symptoms (American Heart Association, 2020). The ECHO will show me valve changes and will confirm my diagnosis. If lifestyle changes are not met to reduce symptoms, medication such as nitroglycerin can be given. If nitroglycerin stops working, further measures such as a coronary angiography will be needed to see the extent of a multi-vessel disease and possible coronary bypass will be needed.
Referral: Cardiologist. If interventions are needed for an acute MI an interventional cardiologist will be recommended. If bypass is needed for advanced blockage, cardiothoracic surgery will be consulted.
Treatment: Since we are in the beginning stages of a cardiovascular event such as stable angina I would recommend to the patient lifestyle changes first. Eating a heart healthy diet with fruits, whole grains, and vegetables, along with moderate exercise daily, and smoking cessation can help with advancing heart disease (Sullivan, 2018).
Medications: If lifestyle alone cannot fix symptoms nitroglycerin can be prescribed. Nitroglycerin 0.4 mg sublingual tablets are prescribed as place one tablet under the tongue. If pain does not completely subside in 5 minutes, take another tablet. Take a max of 3 tablets in 15 minutes. If pain does not subside in 15 minutes, call 911. It is also recommended to take 1 tablet 5-10 min before exercise (Aremu, 2021). One of the more common side effects of nitroglycerin tablet is complaint of headaches, dizziness, weakness, nausea, and fast heart rate. Do not drink alcohol with this medication as it can cause low blood pressure (Aremu, 2021).
Follow-up: If the patient is still symptomatic with nitroglycerin and lifestyle changes, further examination will be done in order to rule out multi-vessel disease and possible interventions such as PCI or bypass. Patient will need to follow up in at least a week with cardiologist to assess effectiveness of medications and treatment.