Shadow health chest pain documentation

Focused Exam: Chest Pain Results | Turned In Advanced Physical Assessment - March 2020, advanced_physical_assessment__td8__031720__sect1

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Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Brain is a 58 you caucasian Male who presents with C/o chest pain in the middle of his chest over his heart, 3 times this month. His pain is 5/10 when the pain arises, no chest pain currently. Chest pain does not radiate to his arm, shoulder or neck. Aggravated chest pain when walking up the steps, and is relieved when he rests. Denies any heartburn, difficult breathing. No change in appetite but mentioned he gained some weight when his bike was stolen. Rare exercise at this moment, desires clearance for exercise since the onset of his chest pain. Never been seen for chest pain, and has not taken anything for chest pain. Medical history: HTN on Lopressor 100 mg/daily x1 year Hyperlipedmia on lipitor 20 mg daily x1 year Omega 3 daily No surgical history Family Medical hx: Father: htn/hyperlipdemia, obesity, died of colon cancer @ 75yo MGF: heart attack died @ 54 yo Sister: HTN and Diabetes type 2 Social hx: beer 3 drinks in a weekend denies tobacco or drug use

Pt. reports "I have been having some troubling chest pain in my chest now and then for the past month." Experiencing periodic c 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 goes away when he rests. Most recent episode was three days a after eating a large restaurant dinner. States “It has never gotten ‘really bad’” so didn’t think it was an emergency, but is concerne after three episodes in one month and wants his heart checked o Reports mild cramping in legs with activity. Denies shortness of breath, indigestion, heartburn. Denies chest pain at this time.

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Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Vitals Document: Provider Notes

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Student Documentation Model Documentation

Objective

Brian is a 58 year old Caucasian male appears to be well-groomed, is pleasant and answers questions clearly and appropriately. He maintains eye contact throughout the exam. He appears in no distress VSS: Bp 146/90 Skin warm to touch, dry, pink and intact. no tenting Heart: S1, s2, s3 and S4 with murmur Carotid pulse: positive Thrill, +3 on right: PMI: displaced laterally, briks and tapping, <3cm Breath sounds: clear in upper lobes, posterior lower lobes with crackles bilaterally. GI: no tenderness, no masses, guarding or distension. BS present at all quads, WNL Liver is palpable and nontender: spleen and kidneys are not palpable Extremties: No edema, Brachial and radial pulse neg for thrill at 2+ popliteal, tibal and dorsalis pedis pulse diminised at 1+. capillary refill less than 3 seconds on extremiteis. EKG: Regular sinus rhythm. No ST changes

• General Survey: 58 year old male is alert and oriented, with clea speech and in no acute distress. • Cardiac: S1, S2, without murmurs or rubs. PMI displaced latera S3 noted at mitral area. • Peripheral Vascular: Right side carotid bruit. JVP 3cm above ste angle. Right carotid pulse with thrill, 3+. Left carotid pulse withou thrill, 2+. Brachial, radial, femoral pulses without thrill, 2+. Poplite tibial, and dorsalis pedis pulses without thrill, 1+. Cap refill less t 3 seconds - 4 extremities. • Respiratory: Breathing is quiet and unlabored. Breath sounds a clear to auscultation in upper lobes and RML. Fine crackles/rales posterior bases of L/R lungs. • Gastrointestinal: Round, soft, non-tender with normoactive bow sounds in 4 quadrants; no abdominal bruits. No tenderness to lig or deep palpation. Tympanic throughout. Liver is 7 cm at the MC and 1 cm below the right costal margin. Spleen and bilateral kidn 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.

Assessment

Coronary Artery disease Stable angina Carotid disease pericarditis Aortic aneurysm r/o GERD R/O Sarcodosis

Based on the abnormal findings during cardiovascular and respiratory auscultation, my differentials include coronary artery disease with stable angina; congestive heart failure; carotid disea aortic aneurysm; pericarditis; or GERD.

Plan

Blood work for cardiac enzyme, electrolytes, CBC, Lipid profile, liver function test, cxr, 12 lead EKG Consult with cardiologist Echocardiogram Exercise stress test Dopplers for carotid Patient should be tested with results on labs at the least, and not discharged home. Baby Asa upon arrival Ntiroglycerin if chest pain is present again Warning signs of when to seek medical help like another onset of chest pain, SOB, shoulder or arm pain

Mr. Foster should receive a 12-lead ECG, chest x-ray, and lab workup (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1 lipid profile, and liver function tests) to confirm a diagnosis. He should be referred for an echocardiogram, exercise stress test, a carotid dopplers as well as a consult with a vascular surgeon for carotid evaluation. Mr. Foster should be prescribed diltiazem and diuretic in addition to his daily Lopressor and Lipitor. If needed, a an ACE inhibitor to manage his hypertension and PRN nitroglyce for chest pain that does not subside with rest.

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