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Brian Foster - Shadow Health information

Shadow Health information
Course

Advanced Health Assessment (NUR 50300)

11 Documents
Students shared 11 documents in this course
Academic year: 2022/2023
Uploaded by:
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This document has been uploaded by a student, just like you, who decided to remain anonymous.
Purdue University

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DOCUMENTATION OF HISTORY AND PHYSICAL EXAM

Patient Name (Initials only) : BF DOB: 8/17/1964 Gender: M Date examined: 10/14/

CHIEF COMPLAINT (reason for the visit)

“I’ve been experiencing this tight, uncomfortable feeling in my chest every now and then. I’m starting to worry it could be something serious.”

HISTORY OF PRESENT ILLNESS (chronology and progression, consider context, OLDCARTS or OPQRST)

Patient is a 58-year-old Caucasian male who presents to the clinic today for an evaluation of chest pain. The patient states he has been “having some troubling chest pain in my chest now and then for the past month.” The patient reports doing yardwork pulling weeds and noticed increasing chest pain. The patient describes pain felt in the middle of the chest felt over the heart. The pain is noticeable after short periods of exercise or exertion lasting a couple of minutes. The pain is described as tight and uncomfortable. The patient reports “feeling a little better after a few minutes of rest.” During these episodes, the patient describes the pain as 5/10 with relief within a few minutes.

Patient has a history of hypertension currently on lisinopril 20mg PO daily, has hyperlipidemia currently taking atorvastatin 20mg PO daily, and reports taking omega-3 fish oil 1200mg PO BID. No hospitalizations or surgeries were reported by the patient. The patient does have a cardiovascular history in the family. Denies any other cardiovascular diagnosis currently.

Today, the patient presents to the clinic with concerns about increasing chest pain episodes over the last month. Currently, the pain is described as 0/10. A full exam was performed. EKG was normal.

PAST MEDICAL HISTORY

Patient reports a diagnosis of high blood pressure and high cholesterol. Denies diabetes, coronary artery disease. Denies previous treatment for chest pain. Patient reports monitoring blood pressure at home, but not on a regular schedule. Denies knowledge of typical blood pressure readings at home. Education was provided to the patient. Recent EKG test was normal. Annual stress test during annual physical. EKG and stress test normal per patient report.

Previous Hospitalizations/Surgery/Trauma Denies hospitalization, previous surgery, or trauma related issues.

Medications (prescribed/OTC/vitamins/supplements/herbal) Lisinopril (Prinivil) 20mg PO Daily, high blood pressure Atorvastatin (Lipitor) 20mg PO daily at bedtime, hyperlipidemia Omega-3-Fish Oil 1200mg PO BID

Allergies/Adverse Reactions Codeine: nausea and vomiting

Immunizations: X Flu ______ Pneumonia 10/2014 Tdap _____Zoster _____Covid

FAMILY HISTORY

Father: hypertension, hyperlipidemia, obesity. Died of colon cancer at age 75.

Mother: type 2 diabetes, hypertension, age 80 Brother: died age 24 in motor vehicle accident Sister: type 2 diabetes, hypertension, age 52 Maternal grandfather: died of heart attack, age 54 Maternal grandmother: died of breast cancer, age 65 Paternal grandmother: died of pneumonia, age 78 Paternal grandfather: died of old age at 85 Son: healthy, age 26 Daughter: asthma, age 19

SOCIAL HISTORY

Lives at home with wife and daughter visits frequently. Patient currently works as a civil engineer. Denies tobacco use. Denies marijuana, cocaine, heroin, or other illicit drug use. Reports social drinking 2-3 alcoholic beverages of beer per week. Reports eating three meals a day Patient reports generally low stress lifestyle. Denies regular exercise routine currently. Last regular exercise was two years ago. Reports seeing healthcare providers every 6 months. Last visit was roughly 3 months ago. Has a primary care provider regularly sees. No apparent financial issues regarding access to healthcare.

REVIEW OF SYSTEMS

(Use lay language when talking to patients; document in medical terms. Describe all positive and pertinent negative findings

Constitutional (fever, chills, night sweats, weight change ,fatigue, malaise, nutrition, deformities, grooming)

Afebrile at current visit. Denies weight loss, dizziness, or lightheadedness. Denies palpitations. Denies fever, chills, night sweats, or general fatigue.

Eyes (vision, pain, discharge, photophobia)

Denies pain. Denies needing glasses. Reports last eye exam was roughly 9 months ago.

Ears/Nose/Throat (altered sensitivity of ears or nose, tinnitus, vertigo, pain, discharge, hoarseness, bleeds, lesions)

No abnormalities discussed. Denies pain, vertigo, hoarseness, bleeds, lesions.

Mouth / Dental (tooth decay, gum disease, last visit to dentist, speech problems, sinus drainage, taste, snoring)

Last dentist visit was roughly a year ago. Denies snoring. Denies any issues with teeth, gums, speech or drainage.

Breast (lumps, nipple discharge, family history of breast cancer, self breast exam)

Denies lumps or nipple discharge. Denies knowledge of breast cancer in family.

Cardiovascular (palpitation, angina, heart attack, chest pain, shortness of breath, PND, orthopnea, claudication, syncope, hypertension, cyanosis, varicosities, edema)

Hypertension diagnosis reported one year ago. Roughly three angina episodes in the last month, Denies palpitations. Denies previous diagnosis of angina. Denies any previous cardiovascular disease problems. Denies syncope, cyanosis, or edema.

PHYSICAL EXAMINATION (Please describe your findings from inspection, palpation, percussion, & auscultation and use the term “deferred” if you did not examine that area.)

Vital signs

Ht 5’11” Wt 197 lbs BMI 27.

Temp 36 C Pulse 104 BP 146/

RR 19 Pain 0/

General Appearance (habitus, level of consciousness, distress)

Patient has overall healthy general appearance. Patient is appropriate in questions, concerns, and awareness of medical history. Does not appear to be in any distress.

1. Head

No visible abnormal findings. Scalp symmetrical. No trauma present.

  1. Eyes Tracks appropriately during conversation. PERRLA.

  2. Ears/Nose/Throat

Deferred. Not assessed at this time.

  1. Mouth / Dental

Deferred. Not assessed at this time.

  1. Neck

Symmetrical, trachea midline

6. Respiratory

Breath sounds present in all areas. Fine crackles. Respiratory rate of 19.

  1. Cardiovascular

S1, S2, and S3 heard. Gallop present. No edema. JVD 4cm or less above the sternal angle.

  1. Gastrointestinal

Bowel sounds active in all quadrants. Abdomen is symmetric and round.

  1. Genitourinary/Gynecological

Deferred. Not assessed at this time.

  1. Lymphatic (palpation of nodes in 2 or more areas)

Deferred. Not assessed at this time.

  1. Skin

Overall appearance is natural. No tenting.

  1. Back, Extremities, Musculoskeletal

Patient is sitting upright and comfortably. Able to move from upright to laying down position.

  1. Neurological

Patient is alert. Oriented to person, place, time, and situation. Appears comfortable. Good historian.

  1. Psychiatric

Reports low stress life. Adequate support system. Maintains good eye contact throughout visit.

Previous Diagnostic Testing/Lab Results EKG: normal finding Annual stress test: normal finding

List 3 Differential Diagnoses with Rationale (pertinent positive and negative)

  1. Angina pectoris, as evidence by chief complaint “I’ve been experiencing this tight, uncomfortable feeling in my chest every now and then. I’m starting to worry it could be something serious.”

  2. Hypertension as evidenced by patient chart of previous hypotension diagnosis, BP 146/90 at current visit.

  3. Hyperlipidemia as evidence by previous diagnosis in patient chart

ASSESSMENT (final diagnoses with ICD-10 code)

  1. Angina Pectoris (IDC-10: 120) o EKG was normal, no ST elevation noted o Sublingual Nitroglycerin by prescription for treatment of angina episodes o Sublingual Nitroglycerin 1 packet placed under tongue every 5 minutes as needed for up to 15 minutes. Do not exceed more than 3 packets in 15 minutes (Mayo Clinic, n.). o Referral to Cardiologist for further management, cardiac workup o Educate the patient if experiencing 10/10 chest pain to go to the local emergency department for further evaluation o Educate to eat less sodium, especially with hypertension diagnosis o Educate to eat lean meats, fruits, and vegetables o Educate patient on prevention methods and associated aggravating factors o Follow up with primary care provider in four weeks
  2. Hypertension (IDC-10: 110) o Blood Pressure check on right and left arm o Auscultated heart tones and breath sounds o Continue lisinopril (Prinivil) 20mg PO Daily o No edema present on this visit o EKG obtained, normal findings
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Brian Foster - Shadow Health information

Course: Advanced Health Assessment (NUR 50300)

11 Documents
Students shared 11 documents in this course

University: Purdue University

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DOCUMENTATION OF HISTORY AND PHYSICAL EXAM
Patient Name (Initials only) : BF DOB: 8/17/1964 Gender: M Date examined: 10/14/23
CHIEF COMPLAINT (reason for the visit)
“I’ve been experiencing this tight, uncomfortable feeling in my chest every now and then. I’m starting to worry it
could be something serious.”
HISTORY OF PRESENT ILLNESS (chronology and progression, consider context, OLDCARTS or OPQRST)
Patient is a 58-year-old Caucasian male who presents to the clinic today for an evaluation of chest
pain. The patient states he has been “having some troubling chest pain in my chest now and then for the
past month.” The patient reports doing yardwork pulling weeds and noticed increasing chest pain. The
patient describes pain felt in the middle of the chest felt over the heart. The pain is noticeable after short
periods of exercise or exertion lasting a couple of minutes. The pain is described as tight and
uncomfortable. The patient reports “feeling a little better after a few minutes of rest.” During these
episodes, the patient describes the pain as 5/10 with relief within a few minutes.
Patient has a history of hypertension currently on lisinopril 20mg PO daily, has hyperlipidemia
currently taking atorvastatin 20mg PO daily, and reports taking omega-3 fish oil 1200mg PO BID. No
hospitalizations or surgeries were reported by the patient. The patient does have a cardiovascular history in
the family. Denies any other cardiovascular diagnosis currently.
Today, the patient presents to the clinic with concerns about increasing chest pain episodes over the
last month. Currently, the pain is described as 0/10. A full exam was performed. EKG was normal.
PAST MEDICAL HISTORY
Patient reports a diagnosis of high blood pressure and high cholesterol. Denies diabetes, coronary artery
disease. Denies previous treatment for chest pain. Patient reports monitoring blood pressure at home, but
not on a regular schedule. Denies knowledge of typical blood pressure readings at home. Education was
provided to the patient. Recent EKG test was normal. Annual stress test during annual physical. EKG and
stress test normal per patient report.
Previous Hospitalizations/Surgery/Trauma
Denies hospitalization, previous surgery, or trauma related issues.
Medications (prescribed/OTC/vitamins/supplements/herbal)
Lisinopril (Prinivil) 20mg PO Daily, high blood pressure
Atorvastatin (Lipitor) 20mg PO daily at bedtime, hyperlipidemia
Omega-3-Fish Oil 1200mg PO BID
Allergies/Adverse Reactions
Codeine: nausea and vomiting
Immunizations: X Flu ______ Pneumonia 10/2014 Tdap _____Zoster _____Covid
FAMILY HISTORY
Father: hypertension, hyperlipidemia, obesity. Died of colon cancer at age 75.

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