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Brian Foster- Documentation
Advanced Pathophysiology (NURSE 644)
Franklin University
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7/22/22, 8:21 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
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Focused Exam: Chest Pain Results | Completed
Advanced Physical Assessment - Summer 2022, NURS 646 - Q1WW
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Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
Subjective
Brian is presenting today with a complaint of chest pain every now and then for the last month. Onset of pain was about one month ago. Pain occurs in the middle of the chest, over to the heart. Brian states that the pain comes and then is better in a couple minutes. The pain is reported as being like chest tightness with the pain level as a 5 out of 10. Physical exertion and exercise aggravate the pain. Sitting or lying down and resting relieve the pains. Brian states that he does not take anything for the pain.
Pt. reports: "I have been having some troubling chest pain in m chest now and then for the past month." Experiencing periodic pain with exertion such as yard work, as well as with overeating Points to midsternum as location. Describes pain as <tight and uncomfortable= upon movement or exertion. Mentioned an epis upon going up the stairs to bed. Most recent episode was three ago after eating a large restaurant dinner. Denies radiation. Pa for <a few= minutes and goes away when he rests. States <It ha never gotten 8really bad9= so he didn9t think it was an emergenc is concerned after three episodes in one month and wants his h checked out. Last physical was 1 year ago but says he hadn't b checked out for several years prior. His regular diet includes gr meat, some sandwiches, and vegetables. Reports grilling betw 5 times a week, usually red meat. Has fast food for lunch on bu days. 1-2 cups of coffee a day. Denies coughing, shortness of b indigestion, heartburn, jaw pain, fatigue, dizziness, weakness, nausea, vomiting, and diarrhea. Denies chest pain at time of interview. No history of anxiety or depression.
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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, presenting to the clinic with complaints of chest pain over the last month. Brian is dressed appropriately for the weather, and speaks clearly. Brian is well groomed, and free of any odor. General: Brian is supine in hospital bed, with an elevated respiratory rate and showing signs of distress. Cardiovascular: No JVD, HR 104, S1 S2 &S4 with gallops. No carotid bruit or thrill Peripheral Vascular: Capillary refill <3 seconds on bilateral fingers and toes. Pulses 2+. No lower extremity edema Respiratory: Respirations are quiet and unlabored, able to speak in sentences. Neurological: Alert and oriented x 3, follows commands and moves all extremities. Skin: No pallor, redness, induration or purulence noted. EKG: Shows normal sinus rythym with ST segment elevation.
General Survey: Alert and oriented, with clear speech. Sitting comfortably in no acute distress.
Cardiac: S1, S2, without murmurs or rubs. S3 noted at mitral a No swelling or fluid retention present.
Peripheral Vascular: No JVD present. JVP 3 cm above sterna angle. Left carotid no bruit. Right side carotid bruit. Right caroti pulse with thrill, 3+. Brachial, radial, femoral pulses without thril Popliteal, tibial, and dorsalis pedis pulses without thrill, 1+. Cap less than 3 seconds in all 4 extremities.
Respiratory: Breathing is quiet and unlabored. Breath sounds clear to auscultation in upper lobes and RML. Fine crackles in posterior bases of L/R lungs.
Gastrointestinal: Round, soft, non-tender with normoactive bo sounds in all quadrants; no abdominal bruits. No tenderness to or deep palpation. Tympanic throughout. Liver is 7 cm at the M and 1 cm below the right costal margin. Spleen and bilateral kid are not palpable.
Neuro: Alert and oriented x 3, follows commands, moves all extremities. Gross cranial nerves 2-12 bilaterally and grossly in
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.
Assessment
Chest Pain Stable Angina Pectoris Hypertension
Based on the abnormal findings during cardiovascular and resp auscultation, my differentials include coronary artery disease w stable angina; congestive heart failure; carotid disease; aortic aneurysm; pericarditis; or GERD.
Plan
Schedule an electrocardiogram and stress test. Draw labs for updated metabolic and lipid panels. Prescribe Nitroglycerin SL 0 as needed for chest pain. Referral to cardiologist Monitor for bruising and/or bleeding. If pain does not reseovle within 3-5 minutes of taking Nitroglycerin, call 911. Follow up in 1 week.
Mr. Foster should receive a 12-lead ECG, chest x-ray, and lab w (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1C, lipid profile, and liver function tests) to confirm a diagnosis. He shou referred for an echocardiogram, exercise stress test, and carot dopplers as well as a consult with a vascular surgeon for caroti evaluation. Mr. Foster should be prescribed diltiazem and a diu addition to his daily lisinopril and atorvastatin. If needed, add an inhibitor to manage his hypertension and PRN nitroglycerin for pain that does not subside with rest.
Comments
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Brian Foster- Documentation
Course: Advanced Pathophysiology (NURSE 644)
University: Franklin University
