SUBJECTIVE Troy, a 48-year-old male, presents to

SUBJECTIVE Troy, a 48-year-old male, presents to the FNP office with mild to moderate chest pressure with radiation to his back. Troy reports that he was awakened from sleep at 7:00 am with chest pressure, initially described as soreness across his anterior chest and through to his back. His wife drove him to the office to be there when it opened at 9 a.m. She tried to convince Troy to go to the Emergency room; but he emphatically refused, insisting on going to the office first. Upon arrival to the office, you take Troy back to the examination room and instruct the receptionist to call 911. Past medical/surgical history: Diabetes type 2 Family history: He has a family history of premature coronary artery disease. His father died f acute myocardial infarction at age 45. One brother died of AMI at age 49. Social history: He has smoked for 25 years but has reduced his smoking to 1 pack per day since his brother’s death 2 years ago. He has put on 25 pounds since the COVID Pandemic and is generally sedentary. Medications: Troy was diagnosed with type 2 diabetes last year. He has been fairly well controlled with diet and Metformin 500 mg daily. His last hemoglobin A1c 2 months ago was 7.4 Allergies: Latex OBJECTIVE: General: He is anxious and shows Levine’s sign as you enter the office room. He is slightly diaphoretic. He took an oral aspirin on the way to the office. Vital signs: B/P 192/96; P: 102; RR: 22; T: 97.8, His SpO2 is 90% ECG: His stat ECG shows ST segment depression and T wave depression and T wave inversion in leads II and III Cardiovascular: His heart tones are muffled with an S3 gallop. His hands and feet are cool to touch. Radial pulses are 2+. Pedal and posterior tibial pulses are 1+ He has neck vein distention of 5 cm with the head of the bed at 90 degrees. He has no carotid bruits, heaves, or thrusts. His PMI is at the 5 th intercostal space, left mid-clavicular line. Respiratory: He has harsh rhonchi in the upper lobes bilaterally and a non-productive cough. Critical Thinking: Which diagnostic or imaging studies should be considered to assist or confirm the diagnosis? 1. Electrocardiogram 2. Troponin 3. Hemoglobin and Hematocrit 4. Electrolytes 5. BUN and creatinine 6. Transfer to the ER with urgent cardiac catheterization What is the most likely differential diagnosis and why? 1. Acute coronary syndrome 2. Pulmonary embolism 3. Gastric reflux What is your plan of treatment? Are there any referrals needed? Does the patient’s family history impact how you might treat this patient? What are the primary health education issues? What if this patient were female? What if the patient lived in a rural, isolated setting? Are there any standardized guidelines that you should use to assess/treat this case?

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