SHADOW HEALTH Focused Exam- Chest Pain | DOCUMENTATION

Document Content and Description Below

Documentation / Electronic Health Record Document: Vitals Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Patient information... Brian Foster date of birth August 17th, a 58 year old Caucasian male CC: mr. Foster States" I have been having some troubling chest pain in my chest now and then for the past month." HPI: VS: b/p (L) ARM 146/88 mmhg (R) arm 146/90 mmhg MAP 109mmhg HR 109 BPM RR- 19 O2 Sat 98% RA Temp: 36.7 C (98 F) Onset of chest pain one month ago, lasting " few min" pt states, "thought it may be heart burn" reports Tight and uncomfortable right in the middle of the chest. Denies any pain radiating denies any arm pain shoulder pain back pain or neck pain. Pain only last a few minutes. An uncomfortable feeling that lasts a few minutes reporting 3 episodes in the past month and all feels the same. Pain currently a zero when having chest pain is 5 out of 10 on pain scale. Patient describes pain as tight and uncomfortable. Patient denies crushing or burning pain to the chest. Laying down seems to alleviate the pain with a brief rest. Not taking any medications for chest pain. Episodes of chest pain started with physical activity while doing yard work Pt. reports "I have been having some troubling chest pain in my chest now and then for the past month." Experiencing periodic chest pain with exertion such as yard work as well as with overeating. Points to midsternum as location. Describes pain as “tight and uncomfortable.” Denies radiation. Pain lasts for “a few” minutes and goes away when he rests. Most recent episode was three days ago after eating a large restaurant dinner. States “It has never gotten ‘really bad’” so didn’t think it was an emergency, but is concerned after three episodes in one month and wants his heart checked out. Reports mild cramping in legs with activity. Denies shortness of breath, indigestion, heartburn. Denies chest pain at this time. in the second episode was taking stairs at work denies any pain with food. Patient confirms all medications are still current and unchanged. No new allergies noted. Confirms hypertension diagnosis and hyperlipidemia diagnosis denies any angina coronary artery disease or previous chest pain treatments. Patient does not check blood pressure on a regular basis only windows to the doctor states doctor does not seem concerned about his blood pressure Current medications: metoprolol 100 mg one po q day, atorvastatin 20 mg po q day, last dose 10 p.m. yesterday ( hyperlipidemia), omega-3 fish oil 1200mg one po q day last dose, Thursday 8 a.m. over the counter. Denies any aspirin use but takes Tylenol or Motrin when having a headache denies headache are not very often. Report heavy EKG before and stresses both normal lasts all primary care doctors 3mmonths ago. see's pcp every 6months. Allergies: codiene ( n/v) PMHx: hypertension stage 2 diagnosed 1 year ago, hyperlipidemia diagnosed 1 year ago. Denies any surgeries. Influenza uptodate, TDAP 10/2014 Soc Hx: denies any illicit drug use or tobacco use. Patient does report drinks 2 to 3. No unusual stress noted. alcoholic beverages per week (beer) no regular exercise last regular exercise he was 2 years ago. Diet consist of granola bars turkey subs and grilled meat and veggies. Unsure of salt intake. Reports drinking a one liter of water a day. drinks coffee one to two a day . denies illegal drugs and comfirmed alcohol intake. Fam Hx: father- hypertension hyperlipidemia obesity, deceased at age 75 of colon cancer mother- type 2 diabetes and hypertension 80 brother- disease at age 24 MVA sister- type 2 diabetes and hypertension age 52 maternal grandfather- by the age 54 of a heart attack maternal grandmother- died of breast cancer at age 65 paternal grandmother- died of pneumonia at age 78 paternal grandfather- disease at 85 years old"old age" son - healthy age 26 daugther - asthma age 19 ROS- General: denies any fatigue increased sweating fever or recent illness skin no rashes or lesions or skin changes No reports of sore throat or difficulty swallowing no shortness of breath. ROS WNL confirmed family history no changes Student Documentation Model Documentation Objective Exam VS - left arm 146/88 mmhg right arm 146/90 mmhg MAP- 109 mmhg HR 104 BPM RR- 19 o2 sat - 98% RA Temp- 36.7C (98 F) Inspected face no visible abnormal findings. Inspecting for jvd 3 cm above the sternal angle. Chest was inspected with symmetrical all the way around and no visible abnormal findings. Inspected abdomen and is symmetric and flat no abnormal findings visible. Inspected hands bilaterally appearance no visible abnormal findings and no nail changes noted. Inspected lower extremities and toenails bilateral no visible abnormal findings to the lower extremities and examine toenails bilaterally no visible abnormal findings noted inspected legs bilaterally for edema no edema noted. Capillary refill tested in all 10 fingers and all ten toes refill time Less Than 3 seconds. Right carotid artery auscultated Bruit present. no bruit to left auscultation of carotid artery Auscultated heart sounds noted as 1 2 and 3 especially in the mitral valve area Auscultated breath sounds all sounds present noted adventitious sounds to the lower posterior right and left Noting fine crackles and rales. Auscultating abdominal aorta no bruit found. Upon examination of all abdominal arteries no bruit found. Upon auscultation of bowel sounds in all four quadrants present. Upon auscultation of liver and spleen no friction rubs noted. When palpating the right carotid artery noted thrill + 3, left carotid palpation no thrill, +2. Palpated PMI: displaced laterally brisk and tapping and less than 3 cm. Palpated bilateral brachial arteries no thrill 2+. Palpation of the left and right radial pulse no thrill, 2+. Palpated left and right femoral pulse no thrill +2. Upon palpation of bilateral tibial, dorsalis pedis pulse and popliteal pulse no thrill, 1+ dimished bilateral. Upon light palpation of all four abdominal quadrants like pressure no tenderness reported no masses guarding or distention. Upon deep palpation of all four abdominal quadrants no masses are abnormal findings noted. Location of the liver a palpable 1 cm below the right costal margin noted. Palpated spleen not palpable. Palpated right and left kidneys not palpable Skin turgor warm dry no tenting noted. Because all four quadrants of the abdomen no areas of dullness noted. On percussion of the spleen no abnormalities noted. Upon percussion of liver span 7cm in the midclavicular line. EKG performed regular sinus rhythm noted no st-elevation or changes. • General Survey: 58 year old male is alert and oriented, with clear speech and in no acute distress • Cardiac: S1, S2, without murmurs or rubs. PMI displaced laterally. S3 noted at mitral area. • Peripheral Vascular: Right side carotid bruit. JVP 3cm above sternal angle. Right carotid pulse with thrill, 3+. Left carotid pulse without thrill, 2+. Brachial, radial, femoral pulses without thrill, 2+. Popliteal, tibial, and dorsalis pedis pulses without thrill, 1+. Cap refill less than 3 seconds - 4 extremities. • Respiratory: Breathing is quiet and unlabored. Breath sounds are clear to auscultation in upper lobes and RML. Fine crackles/rales in posterior bases of L/R lungs. • Gastrointestinal: Round, soft, non-tender with normoactive bowel sounds in 4 quadrants; no abdominal bruits. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. • Neuro: Alert and oriented x 3, follows commands, moves all extremities. • Skin: Warm, dry, pink, and intact. No tenting. • EKG (interpretation): Regular sinus rhythm. No ST changes. Student Documentation Model Documentation Assessment Diagnosis 1. angina pectoris 2. bilateral basal crackles 3. elevated blood pressure 4. hyperlipidemina 5. inactive lifestyle Coronary artery disease with stable angina. Differential diagnoses include congestive heart failure, carotid disease, aortic aneurysm, pericarditis, or GERD Diagnostics • He should also receive a chest x-ray • Fasting lab workup including cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1C, lipid profile, and liver function tests to confirm a diagnosis Plan 1. Doppler testing of pulses 2. Exercise EKG stress test 3. Refer to Cardiology for echocardiography in CT angiography 4. Prescribed nitroglycerin for symptom management 5. Prescribed aspirin regiment 6. Educate patients on signs of worsening symptoms such as MI, CVA or unstable angina 7. Educate on the importance of a healthy diet and exercise to help control hyperlipidemia 8. Educate on salt intake reduction due to hypertension 9. Instruct patient to seek immediate medical attention if signs or symptoms worsen and follow up as needed Medication • Collaborate with cardiology specialist to prescribe diuretic therapy, titrate off Lopressor and transition to ACE inhibitor for management of blood pressure • Upon future evaluation with cardiology, consider PRN nitroglycerin for chest pain that does not subside with rest Education • Educate patient regarding exercise, diet, and lifestyle modifications Referral [Show More]

Last updated: 1 year ago

Preview 1 out of 4 pages