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3/25/20, 8:31 PMFocused Exam: Chest Pain | Completed | Shadow Health
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Focused Exam: Chest Pain Results | CompletedAdvanced Health Assessment – January 2020, nur634
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Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
Subjective
Mr. Foster is a pleasant 58 years old caucasian man who presentedto the clinic with chief complaints of intermittent chest pain that hasbeen going on for the past month. There is no evidence of acutedistress at this time and he currently denies chest pain. He statesthat his chest pain occured at least three times this month. He states”I feel it mostly in the middle of my chest. over my heart.” He statesthat pain severity at its worst is 5/10, non-radiating, and usually goesafter a couple of minutes. He describes the pain as “mostly feelstight and uncomfortable right in the middle of the chest.” He furtherstates “the pain seems to start when I’m doing something physicaland subsides a little bit with rest.” He denies taking any medicationto relieve his chest pain. He reports history of hypertension andhyperlipidemia and takes Atorvastatin 20mg daily and fish oil forcholesterol and metoprolol 100mg daily for his hypertension. Hereports that he has not been checking his blood pressure at homeand only gets it checked during clinic visits. He states that his lastphysical was about three months ago. Reports ocassional alcoholconsumption. Denies smoking and substance abuse. He deniesshortness of breath, fever or chills and any abdominal dsicomfort. Hedenies history of blood clot and bleeding. He states that his momdied of heart attack.
Pt. reports: “I have been having some troubling chest pain in mychest now and then for the past month.” Experiencing periodic chestpain with exertion such as yard work, as well as with overeating.Points to midsternum as location. Describes pain as “tight anduncomfortable” upon movement or exertion. Mentioned an episodeupon going up the stairs to bed. Most recent episode was three daysago after eating a large restaurant dinner. Denies radiation. Pain lastsfor “a few” minutes and goes away when he rests. States “It hasnever gotten ‘really bad'” so he didn’t think it was an emergency, butis concerned after three episodes in one month and wants his heartchecked out. Last physical was 1 year ago but says he hadn’t beenchecked out for several years prior. His regular diet includes grilledmeat, some sandwiches, and vegetables. Reports grilling between 4-5 times a week, usually red meat. Has fast food for lunch on busydays. 1-2 cups of coffee a day. Denies coughing, shortness ofbreath, indigestion, heartburn, jaw pain, fatigue, dizziness,weakness, nausea, vomiting, and diarrhea. Denies chest pain at timeof interview. No history of anxiety or depression.
• General Survey: Alert and oriented, with clear speech. Sittingcomfortably in no acute distress.
• Cardiac: S1, S2, without murmurs or rubs. S3 noted at mitral area.
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Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Document: Vitals Document: Provider Notes
This study source was downloaded by 100000759230540 from CourseHero.com on 01-11-2022 22:14:47 GMT -06:00
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3/25/20, 8:31 PMFocused Exam: Chest Pain | Completed | Shadow Health
Page 2 of 3https://app.shadowhealth.com/assignment_attempts/6065961
Objective
General Survey: 58 years old male patient is alert and oriented, withclear speech and no acute distress. V/s BP 146/90, HR 104,respiration 19, SpO2 98% on room air and temperatire 36.7C. Facialexpression symmetrical. Cardiac: S1 S2 wit S3 noted at mitral area, without murmurs. Nojugular vein distention. Peripheral Vascular: Capillary refill less than 3 seconds in allextremities. Right carotid pulse with thrill, 3+ and left carotid pulsewithout thrill, 2+. PMI displaced laterally, brisk and tapping, less than3 cm. R/L brachial pulses no thrill, 2+. R/L radial pulses no thrill, 2+.R/L femoral pulses no thrill, 2+. R/L popliteal pulses no thrill 1+. R/Ltibial pulses no thrill 1+. R/L dorsalis pedis pulses no thrill 1+. Allextremities are dry and warm to touch. No edema, varicosities andstasis noted. Respiratory: Breathing is quiet and unlabored. Chest expansionsymmetrical. Breath sounds are clear to ausculation in upper lobes.Fine crackles on pesterior bases of both lungs. Gastrointestinal: Round, soft, nontender with normoactive bowelsounds in all four quadrants, no abnormal bruits. No tenderness topalpation. Tympanic throughout. Liver is 7cm in the midclavicularline. Neuro: Alert and oriented, follows commands EKG: NSR with no ST changes
No swelling or fluid retention present.
• Peripheral Vascular: No JVD present. JVP 3 cm above sternalangle. Left carotid no bruit. Right side carotid bruit. Right carotidpulse with thrill, 3+. Brachial, radial, femoral pulses without thrill, 2+.Popliteal, tibial, and dorsalis pedis pulses without thrill, 1+. Cap refillless than 3 seconds in all 4 extremities.
• Respiratory: Breathing is quiet and unlabored. Breath sounds areclear to auscultation in upper lobes and RML. Fine crackles inposterior bases of L/R lungs.
• Gastrointestinal: Round, soft, non-tender with normoactive bowelsounds in all quadrants; no abdominal bruits. No tenderness to lightor deep palpation. Tympanic throughout. Liver is 7 cm at the MCLand 1 cm below the right costal margin. Spleen and bilateral kidneysare not palpable.
• Neuro: Alert and oriented x 3, follows commands, moves allextremities. Gross cranial nerves 2-12 bilaterally and grossly intact.
• Skin: Warm, dry, pink, and intact. No tenting and no sweating.
• Musculoskeletal: Moves all extremities.
• Psych: Normal affect, cooperative, good eye contact.
• EKG (interpretation): Regular sinus rhythm. No ST changes.
• Gastrointestinal: Round, soft, non-tender with normoactive bowelsounds in 4 quadrants; no abdominal bruits. No tenderness to lightor deep palpation. Tympanic throughout. Liver is 7 cm at the MCLand 1 cm below the right costal margin. Spleen and bilateral kidneysare not palpable.
• Neuro: Alert and oriented x 3, follows commands, moves allextremities.
• Skin: Warm, dry, pink, and intact. No tenting.
• EKG (interpretation): Regular sinus rhythm. No ST changes.
Assessment
Coronary artery disease with stable angina. Possible congestiveheart failure, carotid disease or GERD.
Based on the abnormal findings during cardiovascular andrespiratory auscultation, my differentials include coronary arterydisease with stable angina; congestive heart failure; carotid disease;aortic aneurysm; pericarditis; or GERD.
Plan
1. Since Mr. Foster’s BP is not yet controlled, I will titrate hisLopressor and transition to ACE inhibitor. Will also refer toCardiologist for start of diuretic therapy, PRN nitroglycerin for chestpain, echocardiogram and stress test. May need an additionalconsult with a vascular surgeon for carotid evaluation.2. Cxray, lab workup including cardiac enzyme, electrolyte, CBC,BMP, CMP, Hgb, A1C, lipid profile, and liver function test.3. Educate patient regarding exercise, diet and lifestyle modification.Educate Mr. Foster to seek immediate medical attention if chest painreturns and gets worse. 7. Return to clinic in 5-7 days for follow-up.
Mr. Foster should receive a 12-lead ECG, chest x-ray, and labworkup (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1C,lipid profile, and liver function tests) to confirm a diagnosis. Heshould be referred for an echocardiogram, exercise stress test, andcarotid dopplers as well as a consult with a vascular surgeon forcarotid evaluation. Mr. Foster should be prescribed diltiazem and adiuretic in addition to his daily Lopressor and Lipitor. If needed, addan ACE inhibitor to manage his hypertension and PRN nitroglycerinfor chest pain that does not subside with rest.
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3/25/20, 8:31 PMFocused Exam: Chest Pain | Completed | Shadow Health
Page 3 of 3https://app.shadowhealth.com/assignment_attempts/6065961
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