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What questions would you ask to gather important diagnostic information?
History taking would involve asking the main reason for the patientâ€™s visit to the clinic and any other symptoms associated with it. We will need to find the onset, location, duration, characteristics, associated symptoms, relieving symptoms and any treatment that was taken at home to relieve those symptoms. Subjective data would include:
-Elicit location of pain
-Note effects of pain on activities of daily living
-Note intensity of pain at rest and during activity
-List precipitating factors
-Identify alleviating factors
-Note quality of pain
-Is there radiation of pain?
-Rate pain on a pain scale (Cash & Glass, 2014).
How would you diagnose and manage this 17 year old male whose symptoms include palpitations, fever and malaise?
Diagnosis is made by 12 lead ECG which showed tachycardia with rate of 140 and T-wave inversion in the lateral leads, CBC which showed elevated wbc, elevated troponin level, and echocardiogram that showed regional or segmental wall abnormalities like akinesis or hypokinesis, and left or right ventricular hypertrophy.
He would be advised to restrict activity and take antipyretics for fever, analgesics for pain, and supplemental oxygen for his shortness of breath (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). He will also need IV hydration and cardiac monitoring. Further management will be by referral to cardiologist.
Which diagnostic studies would you recommend for this patient? Include the rationale for ALL diagnostics and Labs?
Lab tests for this patient will include:
CBC to look for signs of infection,
BMP to look for electrolyte disturbances that could be causing these symptoms,
D-dimer to check for pulmonary embolus,
Chest x-ray AP and lateral to check for infiltrates in the lungs, size of heart or any other abnormality to rule out pneumonia or cardiomyopathy,
CT chest to rule out pulmonary embolism,
Troponin to look for any myocardial injury,
12 lead ECG to evaluate the heart rhythm and any abnormalities that could be causing tachycardia and palpitations.
Echocardiogram to evaluate all the chambers, valves and walls of the heart
What physical exam findings and diagnostic results would be concerning to you and why? What would be three differentials in this case? Identify additional life threatening diagnoses that must be considered when a patient presents with acute chest pain.
Physical exam findings and diagnostic results that would be concerning are fever, tachycardia, tachypnea, dyspnea, elevated troponin, abnormal ECG, abnormal echocardiogram, and leukocytosis. Fever, tachycardia and tachypnea can occur in any infection and point to SIRS which means that the patient could be in sepsis. ECG showed t wave inversion in the lateral leads and tachycardia of 140. Elevated troponin occurs as a sign of myocardial injury which could be due to myocardial infarction, myocarditis, and pulmonary embolism. ECG and elevated troponins both point to an abnormal condition in the heart. This was confirmed by echocardiogram that showed akinesis or hypokinesis of the heart. Echocardiography remains the most common tool to assess left ventricular structure and function in pediatrics. Although the most common echocardiographic finding associated with myocarditis is a dilated cardiomyopathy phenotype of left ventricular dilatation and reduced ejection fraction, hypertrophic and restrictive phenotypes have been described in histologically proven myocarditis. Segmental wall motion abnormalities mimicking an ischemic cardiomyopathy can be observed (Canter & Simpson, 2014).
The three differentials in this case would include myocarditis, pneumonia, and sepsis. Additional life threatening diagnoses that must be considered in patients with acute chest pain include acute coronary syndrome, myocardial infarction, pericarditis, and pulmonary embolism.
What is the treatment (including rationale) for Robert and education for the family?
Treatment for Robert would include the following:
-Establish IVs, supplemental oxygen, and cardiac monitoring.
-Obtain serial electrocardiograms.
-Administer IV analgesia for chest pain.
– Provide antipyretics for fever.
-Perform a bedside transthoracic echocardiogram.
-Obtain a cardiology consult in the ED.
-Admit the patient to an appropriate, monitored setting.
Robert and his family must be provided careful and sensitive explanation about the cause of the condition, rationale for testing, and a realistic appraisal of clinical status as they must be very anxious about the condition. Robert must be educated about importance of avoiding stimulating situations and substances like caffeine, chocolate, alcohol, and cold medications as they might increase tachycardia and palpitations that are already present in this condition. It is also important to restrict activity and avoid any physical exercise, even house work and driving during the acute phase. He should be seen regularly for support and guidance during the lengthy convalescent period. He should be educated about the importance of yearly flu vaccine (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013).
Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, L. (2013). Primary care: A collaborative practice (4th ed.). St Louis, MO: Elsevier Mosby
Canter, C. E., & Simpson, K. E. (2014). Diagnosis and treatment of myocarditis in children in the current era. Circulation, 129(1), 115-128. Retrieved from http://circ.ahajournals.org/content/129/1/115