Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA: “I have been having some troubling chest pain in my chest now and then for the past month.”
Chief Complaint (CC): The patient is here with a chief complaint of chest pain intermittently for past one month.
History of Present Illness (HPI): Mr. Brian Foster, a 58-year-old Caucasian male, presented to the clinic reporting episodic chest discomfort characterized by sensations of tightness. The onset of this chest discomfort occurred earlier this month. Initially, he attributed these symptoms to a potential episode of heartburn and expected them to spontaneously subside within a few minutes.
Currently, the patient is not experiencing chest pain; however, when the discomfort does manifest, he rates it as a 5 out of 10 on the pain scale. Mr. Foster describes the pain as a sensation of tightness and discomfort localized to the central thoracic region.
He notes that these chest discomfort episodes have occurred three times in the past month, consistently resolving within a few minutes. Furthermore, Mr. Foster reports that the onset of chest discomfort coincides with physical exertion. The first occurrence transpired during yard work. The symptoms resolved when he ceased physical activity and rested.
Medications:
· Lisinopril (Prinivil) 20 mg by mouth daily for hypertension.
· Atorvastatin (Lipitor) 20 mg PO daily at bedtime – last dose 10 pm yesterday. Reason: hypercholesteremia.
· Omega-3 Fish Oil 1200 mg by mouth twice a day (OTC Supplement).
Allergies:
Allergic to codeine: causes nausea and vomiting. No known allergies to food. No known seasonal allergies. No known allergies to latex.
Past Medical History (PMH): Hypertension: diagnosed approximately a year ago. Hyperlipidemia: diagnosed approximately a year ago. No past hospitalizations. Last EKG approximately 3 months ago: normal, per patient.
Past Surgical History (PSH): No past surgical history.
Sexual/Reproductive History: No significant issues.
Personal/Social History:
The patient is a non-smoker. In terms of alcohol consumption, the patient limits intake to a maximum of two to three beers on weekends. There is no history of illicit drug use. Although the patient previously engaged in frequent bicycling, this activity was discontinued due to the theft of their bicycle a couple of years ago. The patient typically obtains 6 to 7 hours of sleep per night. Soda consumption is avoided by the patient. On weekdays, the patient consumes two cups of coffee. The patient maintains regular semi-annual visits to a healthcare provider, unless there is an interim medical concern that necessitates more frequent medical attention.
Immunization History: Influenza vaccine received this flu season. Tdap received on 10/2014.
Significant Family History:
Paternal Side:
- Father’s medical history includes obesity, obesity, hyperlipidemia, and high blood pressure. He passed away at the age of 75 due to colon cancer.
- Paternal Grandmother succumbed due to pneumonia at the age of 78.
- Paternal Grandfather’s cause of death was attributed to “old age” at 85 years.
Maternal Side:
- Mother has a medical history of DM-2 and hypertension.
- Maternal Grandmother’s life was cut short by breast cancer at the age of 65.
- Maternal Grandfather experienced a myocardial infarction (MI) and died at the age of 54.
Children:
- Daughter, aged 19, has a diagnosis of asthma.
- Son, aged 26, maintains good health.
Review of Systems (ROS):
General:
· The patient reports no heightened fatigue compared to their usual state.
· There have been no modifications to the patient’s diet.
· The patient denies recent weight loss.
· The patient has not exhibited an elevated body temperature.
Head, Eyes, Ears, Nose, and Throat (HEENT):
· Eyes: The patient has not experienced any visual loss or blurred vision.
· Ears: There is no complaint of hearing impairment. No aural discharge or hearing loss noted.
· Nose: The patient denies sneezing but does complain of a runny nose.
· Throat: There are no complaints of sore throat.
Skin:
· There is no evidence of rash or pruritus.
Cardiovascular:
· The patient reports tightness and discomfort in the chest but denies palpitations or edema.
Respiratory:
· The patient has not experienced shortness of breath and denies any coughing.
Gastrointestinal:
· No abdominal issues have been reported.
Genitourinary:
· The patient has no complaints related to urination, and there are no reports of abdominal discomfort or pain. Normal bowel movements are maintained.
Neurological:
· There have been no reports of headaches or migraines.
Musculoskeletal:
· No problems reported.
Hematologic:
· The patient has not reported any problems related to abnormal bruising, bleeding, or anemia.
Lymphatic System:
· No evidence of enlarged lymph nodes.
Psychiatric:
· There are no reports of psychosis, substance abuse, or depression.
Endocrinologic:
· No endocrinological problems reported.
Allergies:
· The patient has a documented allergy to codeine, which results in nausea and vomiting.
OBJECTIVE DATA
Physical Exam:
Vital Signs:
· Blood Pressure: 146/90 mm Hg
· Heart Rate: 104 bpm
· Respiratory Rate: 19 bpm
· Oxygen Saturation (O2 sat): 98%
· Temperature: 36.7°C
· Height (HT): 5 feet 11 inches
· Weight: 197 pounds
· Body Mass Index (BMI): 27.5
General:
· The patient is alert, oriented to time, place, person, and situation, and is cooperative.
· The patient maintains good posture, exhibits coherent speech, and is appropriately dressed for the situation.
· Grooming and hygiene are satisfactory, with no noticeable odors.
· The patient displays a normal facial expression, manner, affect, and reaction to the situation.
· Motor activity and gait assessment is inconclusive.
Head, Eyes, Ears, Nose, and Throat (HEENT):
· The head is normocephalic.
· PERRLA.
· Eyes exhibit no redness or drainage.
· The oral cavity is pink, moist, and without signs of breakdown.
· No tonsillar edema is observed.
· The neck symmetry present. Trachea midline.
· Jugular venous pressure is measured at 4 cm or less above the sternal angle.
Chest/Lungs:
· The chest symmetry is present, no intercostal retraction, no use of accessory muscles, skin growths, or signs of skin trauma. Equal fall and rise of chest noted.
· Respiration is even as well as unlabored.
· Lung sounds upon auscultation are clear in all four lung lobes.
· Note fine crackles in the left and right posterior lower lobes.
· The patient can speak without difficulty.
Arteries:
· No bruit is detected in the abdominal aorta.
· No bruit is detected in the left and right kidney arteries, bilateral iliac and femoral arteries.
· A bruit is present in the right carotid artery, but not in the left carotid artery.
· A 3+ thrill noted in the right carotid artery.
· No thrill is present in the left carotid artery.
· No thrill is present in the bilateral brachial, radial, and femoral arteries (all with 2+).
· No thrill is present in the bilateral popliteal, tibial, and dorsalis pedis arteries (all with 1+).
Heart/Peripheral Vascular:
· Heart sounds S1, S2, and S3 are detected.
· No valve clicks, friction rubs, or murmurs are noted.
· The point of maximum impulse (PMI) is less than 3 cm, displaced laterally.
Abdomen:
· The abdomen is symmetrical and rounded. No discoloration or abnormal findings noted.
· There is no visible scars or bruising.
· Bowel sounds are normal in all quadrants.
· No tenderness, masses, guarding, distention, muscle resistance, or rigidity are reported upon light palpation.
· No palpable masses are detected with deep palpation.
· The liver is palpable with no friction rub.
· Palpable spleen, no presence of friction rub.
· The kidneys are not palpable.
· The abdomen exhibits normal tympanic resonance, with liver span measuring between 6 and 12 cm.
Hands, Feet, and Fingernails:
· Bilateral hands show no abnormalities or lesions.
· No rash is observed.
· Cap refill is less than 3 seconds in the fingers and toes.
· There is no pallor, cyanosis, splinter hemorrhages, or clubbing noted in bilateral fingernails on upper and lower extremities.
· No visible distortion or swelling is observed.
· There is no pigmentation, ulceration, varicose veins, or edema in the lower extremities.
Genital/Rectal: (Not assessed)
Musculoskeletal: (Not assessed)
Skin:
· The skin is warm, dry, and exhibits no tenting.
EKG:
· Sinus rhythm is observed without ST elevation.
Diagnostic Test/Labs: EKG, Chest X-ray, 2D Echocardiogram. CBC, BMP, Magnesium, Cardiac troponin, BNP.
ASSESSMENT:
Differential Diagnosis:
1. Stable Angina
2. Aortic Stenosis
3. Mitral Valve Regurgitation
Primary Diagnosis/Presumptive Diagnosis: Stable angina.