COURSE:

NGR 6002C: Advanced Health Assessment and Diagnostic

CC: “Chest pain and shortness of breath”

HPI: 19-year-old male presents to you for right sided chest pain and shortness of breath x 1 hours. He is complaining of breathing hard and fast and feels like he cannot catch his breath. The chest pain is sharp and stabbing to the right upper and lower chest wall worse upon movement or inspiration and hurts to breath. No radiation. Nothing seems to improve the pain. He was playing basketball prior to having the pain and shortness of breath. Denies history of orthopnea, cough, or wheezing
PMH: Early history of ‘sore throats’
PSH: Tonsillectomy at age 4yrs
Medications: None
Allergies: Denies drug, food, latex, or environmental allergies.
Family History: Parents and younger brother are all alive and well.
Grandfather on father’s side had Marfan’s syndrome.
Social History: Lives at home with parents and brother in a 3-bedroom house. He is in his first year of college. Taking classes towards a degree in engineering. Denies smoking tobacco or drinking alcohol. Denies drug use except recreational marijuana.
Health Promotion: Immunizations are up to date.
REVIEW OF SYSTEMS:
General – no fever, chills, Fatigue, weakness, weight loss, night sweats, or changes in sleeping patterns.
Skin – denies rashes, abrasions, itching or dryness.
HEENT – denies nasal congestion
Respiratory – Shortness of breath x 1 hours. Denies history of orthopnea, cough, or wheezing
Cardiovascular – Right sided chest pain. Denies palpitations, no history of murmur.
Gastrointestinal – Denies abdominal pain, nausea, vomiting, or indigestion. Good appetite.
Peripheral vascular – Denies leg cramps or edema
Musculoskeletal – Denies arthralgia or myalgia or limited range of motion.
Psychological – Complains of usual daily stress r/t school. No depression or anxiety.
OBJECTIVE/PHYSICAL EXAM FINDINGS:
Vital signs: BP: 116/64, Temperature: 98.5, Pulse: 72, Respirations: 16. Height: 6’4”, Weight: 140
General: Appears stated age. Appears short of breath and in distress.
Skin: Warm and dry, natural color, no rashes, lesions, or abrasions.
HEENT: Normocephalic, TM’s intact, pearly grey, Nasal mucosa pink, turbinates pink, septum midline no tenderness or drainage. Throat: Oral mucosa pink,
Lungs: Breath sounds are audible and essentially clear on the left side of the chest but diminished on the right. No wheezing. Thorax is asymmetrical. Hyperpresence to percussion over the right chest. Tactile fremitus decreased over the right chest. Voice sounds are normal.
Cardiovascular: RRR S1 and S2. No gallop or murmur noted.
Musculoskeletal: Full range of motion without limitations. Pain to right chest not reproducible on palpation.

SOLUTION

Primary/Working Diagnosis:

Pulmonary hypertension

Findings & Citation (leave double spaced): 

Pulmonary hypertension is a form of high blood pressure affecting arteries in the lungs as well as the right side of the heart. Blood vessels in the lungs get narrowed, blocked, or destroyed and the damage slows blood flow in the lungs. The most common symptom is shortness of breath, initially while exercising and eventually while resting. This could be the case with the patient, since he felt the pain after playing basketball. Chest pressure or pain are also indications of possible pulmonary hypertension as well as fatigue, which could be associable with the patient’s engagement in playing basketball (Bickely et al., 2021b, pg. 477).………………………..TO HAVE THIS CASE STUDY SOLVED, PLEASE PURCHASE IT AT $10 ONLY