Pediatric Case Study Of Child With Sore Throat Biology Essay

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Mr. Wong is presenting with a chief complaint of a sore throat. "The goals of assessment and diagnosis are to identify those patients with group A β-hemolytic streptococcus (GABHS) infection (because they are at risk for rheumatic fever and glomerulonephritis), to reduce the possibility of sequelae of peritonsillar and retropharyngeal abscess, and to identify epiglottitis" (Dains, Baumann, & Scheibel, 2007, p. 22). In order to reach a diagnosis for Mr. Wong, a history must be obtained. According to Dains et al (2007), the following questions should be examined to evaluate the patient:

Have you been drooling? Have you been unable to swallow? Have you been unable to lie down? Have you been restless, unable to stay still?

Rationale.

Symptoms associated with epiglottitis, which is an emergency, include sore throat, difficulty swallowing, and respiratory distress. The respiratory distress is characterized by drooling, dyspnea, and inspiratory stridor. Peritonsillar abscess, another emergency, is associated with sore throat, odnyophagia, trismus, and deviation of the soft palate and peritonsillar fold (Dains et al, 2007).

Is anyone else at home sick? Are any of your friends sick? When did the sore throat start? How severe is the pain?

Rationale.

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Exposure to another individual with an illness increases the likelihood of an infection and can help identify a potential cause, bacterial or viral. A sudden onset of a sore throat with intense pain is related to GABHS. A gradual onset of a sore throat is related to infectious mononucleosis. A sore throat associated with viral pharyngitis typically begins one to two days after the onset of other symptoms. The pain associated with influenza and adenovirus is typically severe with edema of the throat. A sore throat due to noninfectious causes has an insidious onset and is associated with less severe pain described as scratchy or annoying. Peritonsillitis is associated with severe throat pain with trismus and the patient refuses to speak (Dains et al, 2007).

Have you had a fever? If so, when did it start and how high has it been? Do you have muscle aches? Have you had any nausea, vomiting, or diarrhea?

Rationale.

A fever associated with GABHS is sudden in onset and rises above 101.5oF with malaise, headache, and painful swallowing as additional symptoms. The temperature with influenza is abrupt in onset and ranges from 100oF to 104oF. A temperature greater than 104oF is associated with adenoviral infection. EBV is accompanied by a low-grade fever. A temperature that is not present for several days and then recurrent fever or a fever that continues for several days is due to peritonsillar abscess. A sore throat without fever is due to noninfectious cause. Influenza and GABHS is associated with systemic complaints (Dains et al, 2007).

Do you have a cough? Have you had a runny nose? If so, what is the color of the drainage? Do you have mucus dripping from the back of your nose down your throat? Do you have any eye redness, discomfort, discharge, or itching? Have you had any hoarseness? Have you been sneezing?

Rationale.

Two or more of the above symptoms indicates a viral infection and rarely accompanies streptococcal pharyngitis. Influenza is associated with several days of fever, cough, and rhinorrhea. A sore, scratchy throat, nasal congestion, cough, and rhinorrhea is associated with viral pharyngitis. Symptoms of allergic pharyngitis is clear nasal discharge, a sore throat due to postnasal drip, watery or itchy eyes, sneezing, and hoarseness. Viral infections are associated with mild conjunctivitis, sneezing, and hoarseness (Dains et al, 2007).

How old are you? Do you smoke? If not, have you ever smoked or do you live with someone that smokes? Are you taking any medications? What other health problems do you have? Are your immunizations up to date?

Rationale.

GABHS is typical in children 5 to 15 years old. Mononucleosis caused by EBV is common in adolescents and young adults and influenza affects all ages. Tobacco smoke, smog, dust, and allergens can irritate the throat. Immunosuppression increases susceptibility to viral infections that produce pharyngeal ulcers. Patients with diabetes mellitus and those taking antibiotics are susceptible to candidiasis. Patients with gastroesophageal reflux disease (GERD) can have a sore throat due to reflux of gastric contents. Lack of immunizations place patients at increased risk of infections (Dains et al, 2007).

Objective assessment.

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After obtaining the answers to the above questions, a focused assessment needs to then be performed; focusing on the chief complaint of sore throat. The following, according to Dains et al (2007), outlines the focused assessment:

Assess the degree of illness.

Rationale.

If the patient appears restless, has stridor, difficulty breathing, drooling, inability to swallow, and an extremely high fever, the patient may have airway obstruction due to epiglottitis and is an emergency. Anything further into the examination could lead to laryngospasms and airway obstruction (Dains et al, 2007).

Inspect the mouth and posterior pharynx. Observe swallowing.

Rationale.

Enlarged papillae on the tongue giving the tongue a strawberry appearance is associated with streptococcal infection. Examine the palatine tonsils, look for edema, assess color, and exudate. Peritonsillar abscess and epiglottitis causes drooling. If epiglottitis is suspected, do not examine the pharynx because this could lead to laryngospasm and airway obstruction. Peritonsillar abscess is associated with edema of the affected tonsil and is moved midline. Bacterial and viral infections have pharyngeal or tonsillar exudate. GABHS has a yellowish exudate. Viral infection exudate is typically white. Group A streptococcal pharyngitis has a bright red uvula with petechiae on the posterior pharynx and palate. Streptococcal phayngitis has doughnut lesions or red, raised hemorrhagic lesions that have a yellow center. Infectious sinusitis has yellow or greenish purulent drainage. Oral candidiasis is associated with white curdlike patches that bleed with scraping. If inspection of the mouth and posterior pharynx are within normal limits, consider a systemic cause of the sore throat (Dains et al, 2007).

Inspect the nasal mucosa, conjunctivae, tympanic membrane, and skin.

Rationale.

An infective process is represented by red, swollen turbinates and an allergic process by pale, boggy turbinates. Infectious sinusitis is associated with purulent discharge and mucoid discharge with allergic rhinitis. Adenovirus causes pharyngoconjunctival fever and is associated with nonpurulent discharge, fever, and pharyngitis. An allergic process is associated with mild conjunctivitis, itchy eyes, and clear, watery discharge. An earache can be due to referred pain from the tonsils (Dains et al, 2007).

Palpate the cervicofacial lymph nodes and abdomen.

Rationale.

The anterior cervical lymph nodes are enlarged and tender with streptococcal pharyngitis and the posterior cervical lymph nodes are enlarged and tender with viral infections. The cardinal sign of infectious mononucleosis is lymphadenopathy. Mononucleosis is associated with splenomegaly in about half of the cases but hepatomegaly is rare (Dains et al, 2007).

Auscultate the lungs.

Rationale.

In adolescents and young adults, a sore throat can be associated with Mycoplasma pneumonia. Other findings with pneumonia would include an area of consolidation and adventitious breath sounds (Dains et al, 2007).

After a focused assessment is complete, a head-to-toe physical assessment needs to be completed to ensure that no other symptoms are overlooked. A focused assessment would rule out an emergency. Vitals signs also need to be obtained to evaluate hemodynamic and respiratory status (Dains et al, 2007)

Laboratory and diagnostic studies.

Once the subjective and objective assessments are complete, laboratory and diagnostic studies need to be completed based upon findings. A throat swab with culture should be completed to rule out GABHS because it is the gold standard of diagnosis for GABHS (Dains et al, 2007). A complete blood cell count with differential detects mononucleosis if the results show 50% lymphocytes and at least 10% atypical lymphocytes (Dains et al, 2007). A computed tomography scan is indicated to rule out an obstruction or swelling of the throat (Dains et al, 2007). An allergic process can be detected by the presence of eosinophils with nasal cytology (Dains et al, 2007).

Differential diagnosis.

The subjective data, objective findings, and results of laboratory and diagnostic studies leads to a list of potential diagnoses. The following list of diagnoses is listed in order of most likely to least likely causes of Mr. Wong's sore throat.

Viral pharyngitis

Rationale.

The majority of sore throats are due to viral infections. The symptoms associated with viral pharyngitis include malaise, fever, headache, cough, and fatigue with an erythematous or pale, boggy, swollen pharynx. There is usually no tonsillar or pharyngeal exudate or tonsillar enlargement noted. Viral pharyngitis typically has upper respiratory tract symptoms of cough and congestion, whereas, streptococcal pharyngitis does not have these symptoms (Dains et al, 2007).

Streptococcal pharyngitis

Rationale.

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Streptococcal tonsillopharyngitis is associated with 30% of children whom seek care for a complaint of a sore throat. The symptoms associated are a temperature of 101.5oF or higher, tonsillar exudates, anterior cervical adenopathy, and a history of recent exposure to someone with GABHS (Dains et al, 2007).

Epiglottitis

Rationale.

H. influenza type b produces infection and edema of the epiglottis and surrounding areas, obstructing the flow of air. Symptoms of epiglottitis includes respiratory distress, sore throat, difficulty with secretions, drooling, pain on swallowing, and a toxic appearance (Dains et al, 2007).

Peritonsillar Abscess

Rationale.

A collection of pus between the tonsil and pillar is a peritonsillar abscess. This is more common in adults but can occur in children. Symptoms include a history of respiratory symptoms, difficulty swallowing, otalgia, malaise, fever, and cervical lymphadenopathy. Trismus, asymmetrical swelling of uvula, tonsils, or posterior pharynx, or a visible abscess are noted on exam (Dains et al, 2007).

Mononucleosis

Rationale.

Mononucleosis is associated with about 5% of sore throat. The primary cause is EBV. Symptoms include a gradual onset, low-grade fever, posterior cervical lymphadenopathy, mild sore throat, malaise, and fatigue (Dains et al, 2007).

Final diagnosis.

Mr. Wong's chief complaint is sore throat. According to Dains et al (2007), the majority of sore throats are viral pharyngitis. A thorough health history, exam, and evaluation would confirm or rule out this diagnosis. Based upon the symptoms of viral pharyngitis, this would be the proposed final diagnosis for Mr. Wong. His statement of being unable to hardly swallow can be due to erythematous or a pale, boggy, and swollen pharynx (Danes et al, 2007). Direct infection of the pharynx, by a virus or bacteria, is typically the most often cause of a sore throat (Vincent, Celestin, & Hussain, 2004). " The 2000 National Ambulatory Medical Care Survey found that acute pharyngitis accounts for 1.1 percent of visits in the primary care setting and is ranked in the top 20 reported primary diagnoses resulting in office visits" (Vincent et al, 2004). Although viral pharyngitis is the most likely cause of Mr. Wong's sore throat, other causes need to be considered and ruled out including systemic causes. These systemic causes can include GERD, rhinitis with postnasal drip, a persistent cough, thyroiditis, allergies, smoking or second-hand smoke exposure, and a foreign body (Vincent et al, 2004).

Adult Case Study

Chief Complaint: 25 year old Martha Meyer comes to the clinic complaining of a headache occurring off and on for the past 3 weeks. When she gets a headache she take 2 Tylenol and lies down. She reports little relief with these measures.

Subjective assessment.

Ms. Meyer's assessment begins with a history, focusing on the chief complaint of a headache. According to Dains et al (2007), the following are questions directed towards a chief complaint of a headache:

How did the headache begin? Have you had this type of headache before? How severe is your pain? Is there a history of recent trauma to the head? If so, did you lose consciousness? Are there any symptoms associated with the headache? What other health problems do you have?

Rationale.

An intracerebral hemorrhage (ICH) caused by a ruptured aneurysm or vascular anomaly presents as a sudden onset of a severe headache described as a thunderclap headache occurring without a history of chronic headaches. The prevalence of a headache associated with ICH increases with age. A sudden onset headache associated with neurological involvement is an emergency. Subarachnoid hemorrhage (SAH) is typically described as the worst headache ever and is associated with a stiff neck, loss of consciousness, nausea and vomiting, phototphobia, papillary dilation, and seizure. SAH is also an emergency. Trauma to the head can cause subdural or epidural bleeding, which leads to loss of consciousness. Minor head injury can cause a headache which is self-limiting and localized. A headache caused by an infective process is accompanied by a fever and stiff neck. The presence of chronic disease can be associated with a headache such as cryptococcal meningitis, encephalitis, or generalized sepsis in an AIDS patient; patients on anticoagulation therapy; or metabolic disorders such as hyponatremia, uremia, hypoglycemia, and hypercapnia (Dains et al, 2007).

Describe your headache? Where does it hurt? What makes it worse/better? How long have you had this headache?

Rationale.

Dilation of cervical arteries causes a moderately intense headache that is constantly throbbing. An expanding lesion is associated with a severe headache. A steady or throbbing headache that is typically on the same side and takes three to four hours to reach its peak pain level is a migraine headache. Tension headaches occur during times of stress and disappear with relaxation and are described as a hatband type of pain. Cluster headaches are uncommon in children and last less than three hours and occur in clusters. Sound, odor, estrogen fluctuations with menstrual cycles, red wine, chocolate, and ripe cheese is typical triggers to migraine headaches. An aura can precede a headache or occur simultaneous. Tension headaches typically respond to mild analgesics. Migraine headaches can be relieved for some patients by rest in a dark, quiet environment and are made worse with exertion. Cluster headaches are worse when the patient lies down. A tumor that causes a headache is worse in the morning and then improves (Dains et al, 2007).

How often does your headache occur? Can you describe a pattern to the headaches? How long does the headache last? Do you drink alcohol? What medications do you take?

Rationale.

"As a rule, a patient with a persistent headache for more than 3 months may demonstrate physical findings such as papilledema, bilateral or unilateral cranial nerve VI (abducens) palsies, gait or balance disturbances, or spasticity of the lower extremities. If a headache has been present continuously for more than 4 weeks without accompanying neurological signs or symptom, it is most likely psychogenic in origin, especially if coupled with prolonged school or work absences, increased stress, and depression" (Dains et al, 2007, p. 398). Tension headaches occur throughout the day. A sinus headache starts after rising and then gets worse as the day progresses. Migraine headaches are episodic and cluster headaches occur daily for several weeks and then do not occur for several weeks. Headaches can be acute which are organic in cause, subacute, or chronic which are vascular inflammation or muscle tension in cause. Migraine and cluster headaches can be triggered by alcohol but tension headaches may be relieved by alcohol. A headache can be caused by withdrawal from certain substances including caffeine and nitrates (Dains et al, 2007).

Do you have any nausea or vomiting with your headaches? Do you notice any vision changes? Does light bother you? Are you dizzy with your headaches?

Rationale.

Vomiting associated with a headache can be a sign of increased intracranial pressure (ICP). Migraine headaches typically have an aura that precedes them and photophobia is present. Tension headaches are not associated with photophobia. Vertigo associated with a migraine headache may appear as an aura, during the headache, or separately of the headache (Dains et al, 2007).

Does anyone else in your family have headaches? Could you have been exposed to carbon monoxide?

Rationale.

Tension headaches do not run in families, whereas, migraine headaches do run in families. A severe, throbbing, generalized headache can be due to exposure to carbon monoxide (Dains et al, 2007).

Objective assessment.

The physical examination of a patient presenting with a headache should begin with an assessment of orientation. An emergency would be indicated if the pt has ataxic gait, uncoordinated movements, or a decreased mental status (Dains et al, 2007). Ptosis of the eyelid on examination could indicate a cluster headache or brain tumor (Dains et al, 2007). Photophobia can be observed as blinking and squinting of the eyes (Dains et al, 2007). After observing the patient and ruling out any indication of an emergency. The practitioner can proceed with a focused assessment and then move to a complete head-to-toe assessment.

Take vital signs.

Rationale.

A fever may be the only indication of an infection. Increased ICP will present with bradycardia and narrowing of pulse pressure (Dains et al, 2007).

Palpate and percuss the skull.

Rationale.

The temporal arteries should be palpated for pulse and tenderness. Tension headaches are associated with focal tenderness and induration. Temporal arteritis presents as tenderness over nodular temporal arteries (Dains et al, 2007).

Auscultate the cranium.

Rationale.

The cranium should be auscultated for cranial bruits. Migraines can be mimicked by intracranial arteriovenous malformation (Dains et al, 2007).

Inspect the ears, eyes, nose, mouth, and TMJ. Examine the neck.

Rationale.

Inspection of the face, head, and neck can rule out organic causes of heachaches. Examination of the ears can rule out infection. Cluster headaches can cause ipsilateral lacrimation, ptosis, and papillary constriction. Sinus headaches cause rhinorrhea and congestion. Poor dentition, upper molar disease, and TMJ instability can cause a headache. Organic cause of a headache should be questioned if papillary dilation outlasts the headache. Stiffness or difficulty in movement of the neck can be due to muscle tension or meningimus (Dains et al, 2007).

Assess cranial nerve function. Assess motor strength and coordination of extremities. Test balance and gait.

Rationale.

The cranial nerve function can provide information into a more serious cause of a headache due to inflammation, traction, or metabolic imbalance. Lesions can be determined by the assessment of motor strength, coordination of extremities, balance and gait (Dains et al, 2007).

Laboratory and diagnostic studies.

Based upon the results from the history and physical examination, laboratory and diagnostic studies can further confirm a potential diagnosis or rule out a potential diagnosis. A computed tomography scan is the most common diagnostic study and should be done in patients with a new onset headache or one that is associated with neurological abnormalities (Dains et al, 2007). A CT scan can rule out intracranial disease and brain abscess (Dains et al, 2007). Blood cultures can be done in a patient with a headache that is accompanied by a temperature to rule out an infective process (Dains et al, 2007). A lumbar puncture can be done when a central nervous infection is suspected but is a contraindication if increased ICP is suspected (Dains et al, 2007). If temporal arterities is suspected erythrocyte sedimentation rate should be tested (Dains et al, 2007).

Differential diagnosis.

The following list of differential diagnoses are listed in order of most likely to least likely based up Ms. Meyer's complaint of off and on headache for three weeks.

Tension-type headache

Rationale.

Tension headaches are the most common heachache in adults and women. It produces bilateral general or localized pain, which can be described as mild to moderate, nonthrobbing, tightness, or pressure with a gradual onset. It can last for hours or days and can recur over weeks or months (Dains et al, 2007).

Migraine headache

Rationale.

Migraine headaches affect about 20% of adults. It produces unilateral and throbbing pain and is associated with nausea, photophobia, and exacerbation with physical activity. It occurs rapidly and increases within hours. They recur daily, weekly, or less often (Dains et al, 2007).

Cluster headache

Rationale.

Cluster headaches are the least common headache and occurs more often in men. It produces unilateral, ocular, or periocular pain which is described as burning, piercing, or neuralgic. Its onset is abrupt, typically during the night, and severity steadily increases. It occurs in episodes and is clustered in cycles of days or weeks. It cannot recur for months to years (Dains et al, 2007).

Final diagnosis.

Ms. Meyer most likely suffers from tension headaches. Tension headaches are typically due to stress from school or work. "About 30%-80% of the adult U.S. population suffers from occasional tension headaches; approximately 3% suffer from chronic daily tension headaches. Women are twice as likely to suffer from tension-type headaches as men" ("Tension Headaches," 2010). Taking Ms. Meyer's age into account, along with her description of symptoms, migraine headaches and cluster headaches can be ruled out. Tension headaches are not associated with neurological symptoms such as muscle weakness or blurred vision, sensitivity to light or noise, nausea and vomiting, or stomach pain ("Tension Headaches," 2010). A complete history, physical examination, and laboratory and diagnostic tests need to be complete to confirm a diagnosis.

Older Adult Case Study

Chief Complaint: 70 year old Harold Cummings presents at the urgent care center complaining of chest pain which began 20 minutes ago. He is accompanied by his wife who is crying and fearful about leaving her husband.

Subjective assessment.

"The identification of potentially acute life-threatening situation must be determined immediately" (Dains et al, 2007, p. 103). Chest pain can be a symptom of life-threatening disease processes and should be ruled out prior to a history and physical examination for quick treatment. According to Dains et al (2007), the following are questions that should be asked upon a patient presenting with chest pain:

Describe the pain; is it dull, sore, stabbing, burning, or squeezing? What were you doing when it started? What other symptoms have you noticed?

Rationale.

Chest pain can be associated with numerous disorders. Anginal pain is heaviness, pressure, or squeezing which is provoked by exertion and relieved with rest or nitroglycerin. This type of pain may radiate to the left shoulder and down the arm and to the neck and lower jaw. It occurs during exercise, exertion, or emotional stress. Chest pain accompanying a myocardial infarction is not relieved by rest or nitroglycerin and occurs at any time. It is accompanied by nausea, vomiting, diaphoresis, shortness of breath, and syncope. Aortic dissection is an abrupt tearing pain, localized anteriorly or posteriorly in the chest. The patient is able to point to the area of the chest pain with pulmonary edema and is described as gripping, stabbing pain. Pulmonary edema is associated with dyspnea and is sudden in onset. A PE is accompanied with shortness of breath, apprehension, hemoptysis, and the chest pain increases with deep breathing. A sharp, tearing pain that is located in the lateral thorax and radiates to the ipsilateral shoulder is associated with a pneumothorax. It is typically precipitated by coughing or straining. Pneumonia chest pain is burning or stabbing and is located over the infiltration and does not radiate. It is accompanied by fever, cough, and thick sputum (Dains et al, 2007).

Do you smoke? Do you have high blood pressure, diabetes, or heart disease? Do you have a history or a family history of myocardial infarction?

Rationale.

Smoking, hypertension, diabetes, hyperlipidemia, obesity, and a family history of heart disease are risk factors that increase the risk of coronary artery disease (CAD) (Dains et al, 2007).

Do you have a cough or a change in your usual cough? Do you cough up sputum? If so, what color and how much? Do you have a fever? Are you lightheaded or dizzy? Do you feel like your heart is racing?

Rationale.

Pneumonia is associated with chest pain and a cough, colored sputum, and fever. Chest pain can result from decreased coronary blood flow due to arrhythmias caused by hypoxia, trauma, or electrical shock. A rapid heartbeat can be due to caffeine, stress, and hormonal changes. Supraventricular tachycardia can be perceived as palpitations and can be arrhythmias caused by β-adrenergic agents or theophylline (Dains et al, 2007).

Describe your recent physical activities? Have you had any injury to the chest? Does chest movement or position make the pain better or worse?

Rationale.

Any chest pain associated with or after exercise should be investigated as cardiac in origin. Chest pain that is cardiac in origin is typically not affected by respirations. Pleural chest pain is associated with pain on inspiration. Esophagitis associated chest pain can be due to lying flat, consuming alcohol, taking aspirin, easting a spicy meal, and wearing tight clothing (Dains et al, 2007).

Does the pain get better or worse from eating? Do you have blood in your stools? Have you vomited any blood?

Rationale.

"Differentiating between esophageal and cardiac origin of chest pain can present a challenge because the character and location of the pain may be very similar" (Dains et al, 2007, p. 107). Esophagitis chest pain is described as heartburn, or a dull, burning feeling in the epigastric and retrosternal area. It is typically related to eating meals or particular foods. Right anterior chest pain that is radiating to the shoulder or upper back is associated with cholecystitis. Excruciating and constant chest pain to the left upper quadrant of the abdomen radiating to the chest, shoulder, and arm is associated with acute pancreatitis (Dains et al, 2007).

Objective assessment.

After a thorough history, a focused physical examination should be performed followed by a head-to-toes assessment. The exam should begin with the cardiovascular system due to its urgency in treatment for survival and then progress to respiratory and gastrointestinal. According to Dains et al (2007), the following assessments need to be performed to identify the cause of Mr. Cumming's chest pain:

Observe general appearance.

Rationale.

The patient needs to be observed for grimacing, diaphoresis, pallor, cyanosis, tachypnea, use of accessory muscles for breathing, splinting of the chest wall, and unequal chest wall excursion. Observation can begin to clue the practitioner into or away from myocardial infarction or pulmonary edema as potential diagnosis. A patient experiencing a MI will be diaphoretic, pale, and anxious, whereas, with a PE the patient will appear diaphoretic and anxious with rapid respiration and splinting the chest (Dains et al, 2007).

Measure vital signs and respiratory patterns. Obtain electrocardiogram.

Rationale.

An electrocardiogram is an excellent tool to diagnose acute chest pain. Patients presenting with angina will have vital signs within normal limits, whereas, with a MI the blood pressure is elevated and cardiac arrhythmias are present. With an aortic dissection the patient may be hypotensive and have unequal peripheral pulses. Tachypnea and unequal chest wall excursion is characteristic of pneumothorax. Patients with GI associated chest pain will have a rate, rhythm, and depth of respirations that is not changed (Dains et al, 2007).

Auscultate breath sounds and heart sounds.

Rationale.

A PE will have adventitious sounds associated with crackles and rhonchi is associated with pneumonia. A S3 heart tone or mitral regurgitation murmur is typical of myocardial ischemia or congestive heart failure. A S4 heart tone is typical of a stressed heart associated with hypertension, MI, or CAD (Dains et al, 2007).

Examine the abdomen.

Rationale.

Auscultate the abdomen for bowel tones. Esophagitis or peptic ulcer disease is associated with epigastric pain with palpation. Right upper quadrant pain on palpation indicates cholelithiasis or cholecystitis, whereas, left upper quadrant pain is associated with pancreatitis (Dains et al, 2007).

Laboratory and diagnostic studies.

Based upon the history and physical examination, laboratory and diagnostic studies need to be performed. An ECG will indicate myocardial injury with ST elevation or depression or ischemia with T wave inversion (Dains et al, 2007). Cardiac enzymes, which are creatinine kinase-MB and troponins T and I, if elevated are associated with myocardial injury (Dains et al, 2007). Chest radiography can rule out pneumothorax and pneumonia (Dains et al, 2007). Elevated amylase and lipase indicates pancreatitis (Dains et al, 2007). An abdominal ultrasound can be used to detect pancreatitis and gallbladder disease (Dains et al, 2007). An upper endoscopy can be used to rule out GERD (Dains et al, 2007).

Differential diagnosis.

Mr. Cumming's presented to the urgent care center with a chief complaint of chest pain that began 20 minutes ago. The following is a list of potential diagnoses based upon this chief complaint occurring from most likely to least likely:

Acute myocardial infarction

Rationale.

The patient that presents with an acute MI describes pain as persistent, severe, deep, central chest pain and can radiate to the throat or neck, shoulder, and down the arm. The pain is not relieved by rest or nitroglycerin. The chest pain from a MI is also associated with shortness of breath, nausea, vomiting, and diaphoresis (Dains et al, 2007).

Acute pancreatitis

Rationale.

Acute pancreatitis is typically sudden in onset and associated with severe, steady upper epigastric or left upper quadrant abdominal pain that radiates to the left anterior chest, shoulders, or back. The patient will be restless with nausea, vomiting, hypotension, and unexplained shock. The pain is typically worse in supine position (Dains et al, 2007).

Acute coronary insufficiency

Rationale.

Chest pain that is caused by a lack of oxygen to the myocardium without evidence of an infarct is associated with acute coronary insufficiency. The pain lasts longer than 30 minutes and is described as severe, oppressive, constricting, retrosternal discomfort (Dains et al, 2007).

Stable angina

Rationale.

Substernal chest pressure or heaviness that radiates to the left shoulder and arm, neck, or jaw is associated with stable angina. The pain is associated with nausea, diaphoresis, and shortness of breath that comes on gradual and is exacerbated by exercise and stress and relieved by rest or nitroglycerin. The chest pain typically lasts two to ten minutes (Dains et al, 2007).

Esophagitis

Rationale.

The pain associated with esophagitis mimics angina. Patients report the pain with esophagitis to be worse after eating spicy foods, eating large meals, or lying down after eating (Dains et al, 2007).

Final diagnosis.

Based upon Mr. Cumming's presenting symptom, the final diagnosis may be acute myocardial infarction. When a patient presents with chest pain, acute MI must be ruled out prior to investigating a different cause to the chest pain. The final diagnosis of acute MI is due to the emergent situation presented with chest pain symptoms. The chest pain associated with a MI can be mild, especially in an older adult (Seidel et al, 2010). Even though the chest pain is lasting longer than typical myocardial infarction or angina chest pain, MI and angina cannot be ruled out until a cardiac work-up is completed. A patient presenting with any type of chest pain requires cardiac to be ruled out prior to proceeding to respiratory or GI causes.