Comprehensive Case Study- Expert Evaluation of a 69-Year-Old Male Presenting with Chest Pain in an O

Comprehensive Case Study: Expert Evaluation of a 69-YearOld Male Presenting with Chest Pain in an Outpatient Clinic Setting | iHuman Case Analysis Week #4

VERSION A

HX

HX Performance

Exams Feedback

Exercise #1

My Findings vs Case Findings

Problem Statement Feedback

Differential Feedback Differential Ranking

Selected Tests Feedback:

Final Diagnosis Feedback

My Plan:

Plan Feedback:

VERSION B

CC: 62 y/o M Chief complaint is a short 1-2 statement or word phrase from patient and should be listed in “quotes”

“My back is killing me. … it is so bad I can’t think about anything else.”

HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts Mr. Newton is a 62-year-old mal patient presenting to the clinic with complaint of acute onset lower back pain of 11/10 intensity. He describes the quality of the pain as sharp, stabbing that radiate to the back of lower extremities with the right side the most uncomfortable. Patient has history of significant moderate intensity chronic lower back pain for 2-3 months. He has a history of high blood pressure and BPH for which he has stopped taking medication he also has history of hepatitis C. He reports that he has not seen a doctor in years. Family medical history is unremarkable. He has a history if intravenous drug use, and cigarette smoking.

Onset: Severe lower back pain that started today; moderate mid-back pain for 23 months Location: Mild pain in middle of back; severe pain in lower back pain (L1-3) that radiates to back of legs and more intense in right lower extremity.

Duration: Moderate mid-back pain is intermittent. Severe lower back pain has persisted since onset in the morning.

Character: Sharp and stabbing pain that is getting worse Aggravating/alleviating factors: Pain gets worse when standing or moving around and unresolved with Tylenol and NSAIDs. Nothing has helped with pain Related symptoms: Pins and needles in the butt area Treatments: Has tried OTC analgesics; Tylenol and Motrin without relief Significance: Pain in mid-back has severity of 3-4 on scale of 1-10 and the lower back pain is as severe as 11/10. Patient cannot walk or cannot think of anything else

Case: Sam Newton Date: April 4, 2021 PMHx child/adult

SurgHx type/when/why/complications

illness/hospitalizations/immunizations

• No serious childhood illnesses except for common colds, coughs, and stomach pain • Benign prostatic hyperplasia, high blood pressure, hepatitis C.

• No surgical history

• No hospitalization FamHx

SHx

Grandparents (if known)/Parents/siblings/children

Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships

• No history on grandparents • Both parents were healthy and died from old age • No children

• Smoked a pack of cigarette a day for 30 years but quit 5 years ago • History of intravenous drug use (Heroin); he has been clean for 30 years • He has down on alcohol consumption; He used to take 4-5 beers a day, but he has cut down.

• Patient works as a environmental cleaning car driver

Reproductive Hx

Allergies (Food, Drug, Environmental, etc.)

Female: Age of menarche/menstruation cycle duration/gravida para status/Childbirth hx/sexual hx and concerns/LMP/menopause Breast/cervical screening (if any) Male: Sexual hx and concerns/issues with fertility (if any)/Testicular or prostate screening (if applicable) Screening for STI’s (if applicable)

• NKA List of Medications/supplements (prescription, OTC, complementary alternative therapies)

• Patient refused to answer question about STDs • He reports he is heterosexual

• • • •

Tamsulosin (Stopped taking it 5 years ago) BP medication (Stopped taking it 5 years ago) Tylenol Motrin

Case: Sam Newton Date: April 4, 2021

Case: Sam Newton Date: April 4, 2021 Review of Systems: (ROS) Use this column to document the ROS below.

General: Denies fever, chills or malaise, weight gain or loss.

HEENT: Denies headaches, double or blurred vision, hearing problems, pain in ears o sinuses, denies nasal drainage, denies sore throat or difficulty swallowing.

Neck/Thyroid: No complaint of any pain or swelling in neck.

Pulmonary: Denies SOB, cough, wheezing, or pain on deep breathing CV: Denies chest pain, palpitations, or decreased exercise tolerance GI: Denies nausea vomiting and anorexia.

Denies diarrhea or constipations.

GU: Denies dysuria or difficulty urinating.

Report of oliguria MS: Complains of severe lower back pain, moderate chronic mid-back pain, and weakness in lower legs Heme: No complaints of bruising or frequent epistaxis Endocrine: No complaint polyuria, polydipsia, polyphagia, or heat/cold intolerance.

Derm: No complaints of unusual moles, rashes, lesions.

Neuro: Reports of tingling and numbness in buttocks. Denies dizziness, seizures or headaches Psych: No complaints of sadness, hopelessness,

From the ROS: list/highlight the current symptoms/complaints to generate a list of pertinent “reported or denied” symptoms below: Pertinent positive ROS: Complains of severe lower back pain of severity of 11/10 on scale of 1-10, moderate chronic mid-back pain of severity of 3-4 on a scale of 0-10, and weakness in lower legs. Report of oliguria. Reports of tingling and numbness in buttocks.

Pertinent negative ROS: Denies fever, chills or malaise, weight gain or loss. .

Case: Sam Newton Date: April 4, 2021 or panic attacks.

Case: Sam Newton Date: April 4, 2021 Physical Exam: (PE) Use this column to document the PE below.

Vitals Temperature: 98.8-degree F/37.1 degree C Pulse: 102 bpm - regular Blood pressure: 154/96 mmHg - supine/sitting Blood pressure: 152/94 mmHg - upon standing Respiratory rate: 16 bpm SpO2: 98% on room air Height: 5' 10" (178.0 cm) Weight: 205 lbs. (93.0 kg) (BMI 29.4)

General: Older male patient with lower pain HEENT: No edema, non-tenderness, lumps or deformities. Normocephalic, atraumatic, face is symmetrical, pupils reactive Neck: No visible scars or deformities of neck, trachea midline Pulmonary: Lungs are clear to auscultation anterior/posterior bilaterally. Chest symmetrical, slightly barrel CV: Tachycardia, elevated blood pressure, normal venous pressure GI: BS normal X 4; Soft with no scars or deformities.

GU: Normal external genitalia, no tenderness or urethral discharge, enlarged nontender prostate with right sided nodules

From the PE: list/highlight the presence or absence of objective findings to generate a list of pertinent “(+) or (-)” symptoms below: Pertinent (+) PE findings: Tachycardia, elevated blood pressure. Thoracic tenderness of T8-9, lumbar tenderness with diffuse muscle spasm of lower back, lower extremity strength indeterminate due to lack of patient participation secondary to severe pain, and bilateral lower extremities weakness. Enlarged femoral lymph nodes. Saddle paresthesia, gait ataxia, and diminished reflexes on right patella. Enlarged nontender prostate with right sided nodules Pertinent (-) PE findings: Normal bilateral bulk and tone. Range of motion normal and equal bilaterally.

Case: Sam Newton Date: April 4, 2021 MS: Normal bilateral bulk and tone. Range of motion normal and equal bilaterally. Thoracic tenderness of T8-9, lumbar tenderness with diffuse muscle spasm of lower back, lower extremity strength indeterminate due to lack of patient participation secondary to severe pain, and bilateral lower extremities weakness.

Lymph: Enlarged femoral lymph nodes Derm: Skin warm, dry. Hair and nails normal.

Skin color appropriate for ethnicity.

Neuro: Saddle paresthesia, gait ataxia, diminished reflexes on right patella Psych: Appropriate speech, judgment, cooperative.

Case: Sam Newton Date: April 4, 2021 Lab/Radiology or other Diagnostic data:

Problem Statement:

• • • •

Mr. Newton is a 62-year-old mal patient presenting to the clinic with complaint of acute onset lower back pain of 11/10 intensity. He describes the quality of the pain as sharp, stabbing that radiate to the back of lower extremities with the right side the most uncomfortable. Patient has history of significant moderate intensity chronic lower back pain for 2-3 months. He has a history of high blood pressure and BPH for which he has stopped taking medication he also has history of hepatitis C. He reports that he has not seen a doctor in years. Family medical history is unremarkable. Physical examination shows patient is tachycardic, with an elevated BP, enlarged nodular prostate, femoral adenopathy, diminished right patella reflex, sciatica upon standing, ataxic gait, BLE weakness, unilateral LE hyporeflexia and saddle paresthesia. He has a history of intravenous drug use and has been clean for 30 year. He has a 30-year 1 pack a day cigarette smoking which he quit 5 years ago. Bone scan shows abnormal sites of metastatic disease including T8, T9, L1, L2, L3, R pelvis, L femoral head, but test is incomplete

• Prostate-specific antigen (PSA): abnormal, suggestive of prostate malignancy

because patient could not tolerate CT due to severe pain. Patient has abnormal PSA which is suggestive of prostate malignancy.

Basic Metabolic Panel (BMP): Normal Complete blood count (CBC): Normal 12 Lead ECG: Normal sinus rhythm Lumbar and thoracic spine MRI: Not completed • Blood culture and sensitivity: Negative • Bone scan total body: Abnormal, normal sites of metastatic disease including T8, T9, L1, L2, L3, R pelvis, L femoral head • CT abdomen/pelvis w/o contrast: Abnormal non-contrast pelvic CT with a markedly enlarged asymmetric prostate, enlarged lymph nodes

IHUMAN TOTAL CASE SCORES: #1: 80% #2: 97%

List the differential diagnoses (Must not Miss/Leading/Alternate/Concluding) *Include ICD 10 codes after each

Case: Sam Newton Date: April 4, 2021 Based on patient’s age/risk factors, what preventive screening would be recommended at todays or a future visit:

• Colorectal Cancer: Screening: adults aged 50 to 75 years

• Healthy Diet and Physical Activity for

Leading/Must not miss Diagnosis Cauda equina syndrome (CES) (G83.4): leading diagnosis due to the saddle paresthesia, ataxic gait, and motor weakness. It is a “must not miss” diagnosis because it is an emergency.

Metastatic cancer (C78.1): This a leading diagnosis because it could be the cause of CES. The history of smoking predisposes him for lung cancer. The abnormal PSA and abnormal bone scan are also indicators.

Cardiovascular Disease Prevention in Adults with Cardiovascular Risk Must not miss Diagnosis Factors: Behavioral Counseling Interventions: adults with cardiovascular Spinal epidural abscess (G06.1): Frequently missed because it is rare and the disease risk factors severity of complications if not caught in time • Type 2 Diabetes Mellitus: Screening: Alternate Diagnosis adults aged 40 to 70 years who are Compression Fracture (S32.02): risk factors for this patient includes history of overweight or obese (BMI > 25) smoking, age, alcohol use.

• Depression in Adults: Screening: general adult population, including pregnant and Disc Herniation (M51.27): Some of the unilateral symptoms makes this a postpartum women (Denies depression)

• STI screening (not currently sexually active)

Case: Sam Newton Date: April 4, 2021 • Unhealthy Drug Use: Screening: adults age 18 years or older (Denies any inappropriate drug use) Weight Loss to Prevent Obesity-Related • Morbidity and Mortality in Adults: Behavioral Interventions: adults •

Lung Cancer: Screening: adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years (USPSTF, 2021)

plausible diagnosis but patient denies any heavy lifting.

Lumbar strain/sprain (S33.5): Neurological findings in this patient is not typical in this condition.

Spinal Stenosis (M48.07): this diagnosis is considered because pain worsens with walking and standing, but the acute onset makes it unlikely.

Conclusion Cauda equina syndrome (CES) caused by metastatic cancer is the correct diagnosis (ICD10data.com, 2021)

*Case Study Template adapted from the following sources: NP H & P (ReNursing.edu, 2018) and IHuman Patients by Kaplan (2020)

Reflective Thinking Exercises 1. History-Taking: Describe your history taking scores and strengths you identified when gathering data. What went well? Also, describe your challenges in gathering data and list areas of your personal needed improvement. Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis.

Case: Sam Newton Date: April 4, 2021 My interview skills have improved overall, but I still miss a few required. In real life, a patient will be annoyed if they are asked questions that they have already answered. Although some answers were already provided because I did ask the specific questions, I missed points. History taking score for first attempt was 79% and 98% on the second attempt 2. Physical Exam: Describe your physical exam scores and strengths you identified when performing selected exams on your patient. Did you perform an excessive amount of exam items? Did you miss any pertinent exam items identified in the case leading to diagnosis? Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis.

Physical exam scores are 85%% for the first attempt and 100% for the second attempt. I continue to make improvement in this area. I decided to perform a more comprehensive examination because patient has not had medical care in 5 years.

3. Evidence-based decision making: Discuss the evidence-based resource(s) utilized while seeing the patient. These can be your course readings/IHUMAN lessons/other course info as well as any external articles or supporting literature to help you gain a better understanding of categorizing possible diagnoses in your case. How did you use the symptoms/patient presentation, plus your exam findings, to formulate a differential diagnosis list? What specific feedback from previous case studies has your faculty identified that you plan to incorporate on future cases to avoid pitfalls in data gathering or decision making? What will you do differently to improve?

The required text readings from S2D and Dain was very beneficial especially S2D with identifying differential diagnosis. As I get more familiar with the course material, again I do not agree with the experts feedback with the differential diagnosis; spinal neoplasm that I added is not incorrect.

References ICD10Data.com. 2021 ICD-10-CM Codes. https://www.icd10data.com/ICD10CM/Codes.

Johnson, N. (2018) NP H & P. ReNursingEdu LLC. www.ReNursingedu.com Kaplan, Inc. (2020). Case study: Emma Ryan. IHuman patients by Kaplan.

Case: Sam Newton Date: April 4, 2021 United States Preventive Services Taskforce (2021). A and B Recommendations: United States Preventive Services Taskforce. A and B Recommendations | United States Preventive Services Taskforce. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations.