Mr J, a 53 year old white male presents to the Emergency Dept (ED) for his third visit in a 3-month period with a chief complaint of epigastric pain. The patient states that he first came to the ED 3 months ago with the complaint, states that his symptoms weren’t that bothersome then but had been present for a couple months, he couldn’t get a same-day appointment with his primary care provider (PCP), and the receptionist at the PCP’s office told him since he had epigastric pain, he should go to the ED to “get checked out.” Pt states that at that first ED visit he had a chest x-ray and an EKG, no bloodwork was done, and he was given a couple prescriptions, one for cough syrup and one for prednisone and that he took all of the prednisone as prescribed but he didn’t take the cough syrup because it made him “feel woozy.” He got no relief from that treatment regimen and followed up with his PCP in the office a couple weeks later; his PCP told him that he hadn’t gotten any communications from the hospital or ED about the findings from the patient’s ED visit. The PCP did a physical exam, another EKG which showed a normal sinus rhythm, and told the patient that he was going to write him a prescription for acid reflux medication, counseled the patient to stop smoking, and to return to the ED if his symptoms got worse. The PCP prescribed carafate 1gm po QID and prilosec 40mg po q day and discharged the patient home with a referral to a gastroenterologist who was in a city about an hour and a half away by car.
The patient presents to your ED with complaints of worsening epigastric pain that hasn’t gotten better with either treatment. He’s back in the ED because 2 days ago he started having a productive cough with greenish-brown sputum that’s worse in the morning when he wakes up. He denies fever, denies known sick contacts (COVID hasn’t happened yet, just FYI). He lives alone in the local area, he’s divorced and has grown children. One of his sons is patient’s partner in a drywall/construction business but the patient handles almost all of the business, particularly the scheduling and the payroll. Business has been booming, he’s been under more pressure/stress lately and patient admits that has been smoking more to calm his nerves even though he admits that he knows that’s not a good practice for him. He denies regular exercise, admits that he has dyspnea on exertion and that has started in the last couple months. He denies orthopnea. He denies any history of known cardiac disease or workup, and he denies family history of early cardiac disease but admits that his parents both have a history of “heart problems,” he doesn’t know any more than that. He says he thinks that both the EKG he had recently (one in this ED, one at his PCP’s office) were normal because no one told him they weren’t normal. He denies illicit drug use, admits to daily ETOH (about 2-3 beers/day, more on the weekend) and admits to smoking 2 ppd cigarettes since he was about 13. He denies daily medications other than those recently prescribed for him, NKDA. Unsure about his immunization status, denies getting a flu shot because he claims he did that once and “it gave me the flu.” Denies fever, chills, admits to night sweats occasionally and intermittent fatigue. Denies peripheral edema. He appears nervous and says he is really frustrated with the healthcare system in this area, that he isn’t getting any better and doesn’t like hospitals or doctors, he wants to know why he hasn’t been accurately diagnosed and treated and how long he’s going to be there in the ED, he says he has business to do.
VS: 163/101, HR 112, RR 22, T 97.9F, pulse ox 91% on RA
1. What other information do you want from this patient to aid in putting together a differential diagnosis/illness script?
2. What are the risk factors for cardiac and pulmonary disease that this patient has? Identify if the risk factors are modifiable or not modifiable and how the patient could reduce his risk factors/what you would recommend to the patient.
3. What are the Guidelines for Treatment recommendations for the top diagnosis on your differential diagnosis/illness script?
4. What do you expect to find on physical exam of this patient when you do a cardiac and respiratory evaluation?
5. Describe the diagnostic workup you would order for this patient and the rationale behind each test/study you would order.
6. What treatment if any do you want to order now, after your exam and before results are back, and why