Name:

Focused Exam: Chest Pain

Subjective

Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. When you are ready to submit your documentation, ‘Save As’ with this title format: “[LastName_FirstName] Shadow Health Documentation Template – Focused Exam_Chest_Pain – NURS 6512”

S. CC: “Chest pain”

HPI: The patient is a 58-year-old white American male who reports pain in the mid chest every no-and-then for the past month. The patient states the pain “feels like tightness than sharp pain” Patient reports pain is in the middle of the chest over the heart and has occurred three times in the past month and goes away after a couple of minutes. Patient rates pain six out of ten in terms of intensity but is currently a zero intensity. The pain is aggravated by physical activity and relieved by rest. The denied taking any medication to relieve the pain.

PMH: Positive for high blood pressure and high cholesterol, checks BP during check-up visits to the doctor every 6months, last labs were drawn 3 months ago. Believes he takes Lisinopril 20mg daily and Atorvastatin 20mg daily for high BP and high cholesterol, respectively. Takes 1200mg fish oil daily, Ibuprofen or Tylenol for pain occasionally, allergy to Codeine causes nausea and vomiting. Denies previous hospitalizations or surgeries.

FH: Dad died at 75 from colon cancer but was overweight and had high blood pressure and high cholesterol prior to death. Mom is 80 and has type 2 diabetes and high blood pressure. Brother died from a car accident at 24 and sister has diabetes and hypertension.

SH: Negative for tobacco or drug use, consumes moderate amount of alcohol (2 to 3 beers on a weekend), lives with wife and kids, has “a couple of good friends I can rely on”, no stress from work. Gained 20 pounds in the last 2 years, denies regular exercise in the last 2 years, typical breakfast is instant shakes or granola bar, lunch is subs or a salad, dinner is grilled meats and vegetables, drinks at least 4 glasses of water daily.

ROS General- Anxious about chest pain, denies stress, sleeps 6-7 hours a night, negative for fever, chills, fatigue, night sweats, dizziness, light-headedness.

Cardiovascular- Denies palpitations, heart murmur, blood clots, rheumatic fever, bleeding and bruising easily, reports EKG 3 months ago and stress test yearly with normal results Gastrointestinal-Negative for diarrhea, abdominal pain, constipation, flatus, bloating, heartburn, nausea, vomiting, indigestion. Pulmonary- Negative for cough, dyspnea, shortness of breath.

Document: Provider Notes – NURS 6512

C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m

1

This study source was downloaded by 100000822789681 from CourseHero.com on 04-15-2021 18:16:01 GMT -05:00

/file/78222222/Focused-Exam-Chest-Paindocx/

Th is

stu dy

re so

ur ce

w as

sh ar

ed v

ia C

ou rs

eH er

o. co

m

Objective

O:

VS: BP 146/90; P 104; R 19; T 36.7; 02 98% Wt 197lbs; Ht 5ft 11 inches

General- Patient appears worried and anxious

Cardiovascular- No jugular vein distention, venous pressure 4cm or less above the sternal angle, chest symmetrical with no visible abnormalities, capillary refill <3sec to bilateral fingers and toes, S1, S2 and S3 heart sounds audible with gallops, thrill noted to right carotid artery with 3+ amplitude, 2+ amplitude and no thrill other arteries, no bruits to abdominal aorta, or abdominal or lower extremity arteries, PMI is in the 5th inter-costal space displaced laterally, brisk and tapping. No cyanosis, clubbing, noted, no lower extremity edema is noted.

Gastrointestinal–The abdomen is rounded and symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; no tenderness, masses, no abnormal observations to abdomen, no abnormality to liver, spleen, kidneys on palpation and percussion. No tenting.

Pulmonary- Positive lung sounds to all areas bilaterally with fine crackles noted to bilateral lower lobes.

Diagnostic results: EKG: Normal sinus rhythm with no ST elevation.

Document: Provider Notes – NURS 6512

C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m

2

This study source was downloaded by 100000822789681 from CourseHero.com on 04-15-2021 18:16:01 GMT -05:00

/file/78222222/Focused-Exam-Chest-Paindocx/

Th is

stu dy

re so

ur ce

w as

sh ar

ed v

ia C

ou rs

eH er

o. co

m

Assessment

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis

should be at the top of the list (#1).

Differential Diagnosis:

1) Angina from Coronary artery disease is caused by damage to the major vessels of the heart usually from plaque buildup and is characterized by a history of cardiovascular disease (CVD), it is common in females ≥65 years or males ≥55 years. In CAD, there could be no pain or there could be pain that increases with exercise and the pain is not reproducible by palpation. The pain in CAD usually has a duration of 1–60 minutes and is located in the substernal area (Harskamp et al., 2019). CAD is high in the list of differential diagnoses because the patient in this case study is a 58 year old male, had pain for only a couple of minutes each time, the pain was not reproducible by palpation, the patient’s pain was also in the substernal area and was described as feeling more like “chest tightness”. All the above and the fact that the patient’s pain also increased with physical activity and the patient’s pain has been intermittent makes CAD the primary diagnosis.

2) Acute coronary syndrome results from the sudden blockage of coronary artery leading to unstable angina or myocardial infarction depending on the location of the blockage and the percentage of the coronary artery that is blocked. Acute coronary syndrome is characterized by the radiation of pain, the presence of nausea/sweating, abnormal EKG, and a history of coronary artery disease (CAD) (Harskamp et al., 2019). Acute coronary syndrome is not the primary diagnosis because the patient did not have a history of CAD, there was no radiation of pain and no nausea/sweating.

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

Document: Provider Notes – NURS 6512

C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m

3

This study source was downloaded by 100000822789681 from CourseHero.com on 04-15-2021 18:16:01 GMT -05:00

/file/78222222/Focused-Exam-Chest-Paindocx/

Th is

stu dy

re so

ur ce

w as

sh ar

ed v

ia C

ou rs

eH er

o. co

m

References

Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W., & van Weert, H. (2019). Chest pain in general practice: a systematic review of prediction rules. BMJ open, 9(2), e027081. /orders/doi.org/10.1136/bmjopen-2018-027081

Document: Provider Notes – NURS 6512

C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m

4

This study source was downloaded by 100000822789681 from CourseHero.com on 04-15-2021 18:16:01 GMT -05:00

/file/78222222/Focused-Exam-Chest-Paindocx/

Th is

stu dy

re so

ur ce

w as

sh ar

ed v

ia C

ou rs

eH er

o. co

m

Powered by TCPDF (www.tcpdf.org)