Chest pain documentation | Nursing homework help

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Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

Name

Institution

Patient Initials: Brian Foster, Age: 58, Race: Caucasian American, Sex: Male

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SUBJECTIVE DATA

Chief Complaint (CC): “Sporadic chest pain.”

History of Present Illness (HPI): BF is a 58-year-year old Caucasian male who came to the

hospital complaining of pain at the center of the chest, which begun in the past month. He reports

that the pain goes away after several minutes. The pain happened during work, and he felt

tightness and pain. The patient reports the pain increases during the activity. He rates the pain as

5/10.

1. Location- the center of the chest

2. Quality- several” minutes

3. Quantity or severity-5 out of 10

4. Timing, including onset, duration, and frequency-past month

5. Setting in which it occurs-Pain happened with yard work as well as taking stairs

6. Factors that have aggravated or relieved the symptom- activity

7. Associated manifestations—tight, uncomfortable, and crushing pain.

Medications: Lopressor 100mg once daily for high blood pressure, Lipitor 20mg once daily for

high cholesterol, fish oil as a supplement 1200mg once a day, Atorvastatin 20 mg daily.

Allergies: Reports being allergic to codeine

Past Medical History (PMH): One year ago, the patient was diagnosed with high blood

pressure and high cholesterol

Past Surgical History (PSH): No report of past surgery.

Sexual/Reproductive History: heterosexual, and sexually active.

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Personal/Social History: The patient does not smoke tobacco. Reports drinking two times a

week. He does not exercise regularly. He drinks about two liters of water a day. His diet is

composed of meat, veggies, and granola. Denies recreational use of medications.

Immunization History: All vaccinations are current, and he received a tetanus vaccine in 2014.

Significant Family History: Dad has high blood pressure and high cholesterol dies at age 75

because of colon cancer. Mom has a history of diabetes mellitus. Sister is asthmatic. Maternal

granddad died of stroke at 54*. Maternal grandma- passed away due to breast cancer at 65.

Paternal grandma- passed away at 78 due to pneumonia. Paternal grandpa died at 85 due to

asthma.

Review of Systems:

General: Denies sweating at night, fever, and feeling tired. Reports increase of weight.

HEENT- denies ear and eye problems. Denies having problems during swallowing and sore

throat.

Cardiovascular/Peripheral Vascular: Denies having blood clots, murmur Angina, palpations,

and irregular heartbeats

Respiratory: Denies shortness of breath, coughing, and report having chest pain.

Gastrointestinal: Denies diarrhea, vomiting, and constipation.

Musculoskeletal: Denies having pain in the joints.

Psychiatric: Denies suicidal thoughts.

Objective data

Physical Exam:

Vital signs: Left arm 146/88 mmhg right arm 146/90 mmhg MAP- 109 mmhg HR 104 BPM

RR- 19 o2 sat – 98% RA Temp- 36.7C

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General: The patient is oriented, alert, and well-groomed and responds to questions

appropriately.

HEENT- Head is symmetric, nose and mouth moist and pink.

Cardiovascular/Peripheral Vascular: S1 S2and S3 present. There is Gallup.

Respiratory: Breathing is quite evident as well as unlabored. Upon auscultation, breath sounds

are all clear upper. Fine crackles in lower bases of L/R lungs.

Gastrointestinal: The stomach region of the patient is soft, on –tender and there are Round, soft,

non-normative bowel sounds in all quadrants. In addition, there are no abdominal bruits and

tenderness on both light and deep palpation. The abdomen organs are Tympanic. The liver is 7

cm and palpable. Spleen is bilateral, and the kidneys are not palpable.

Musculoskeletal: No abnormal finding was recorded.

Neurological: Alert and oriented x 3. The patient can move all body parts and extremities

Skin: Warm, waterless, pink, and whole. No tenting

Diagnostic Test/Labs:

EKG test- shows regular sinus rhythm and no ST changes.

X-rays of chest to determine an abnormality.

Telescope to find out for abnormal sounds on heart and chest.

ASSESSMENT:

Differential Diagnosis

1. Angina pectoris is a chest pain that happens when one part of the heart is not getting adequate

plasma and oxygen. The symptoms of this disease are chest and shoulders pain. Treatment for

this disease involves relieving signs by resting as well as using angina drugs. Another treatment

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involves practicing healthy lifestyles, which in turn improves the overall health of the person.

The patient may have this condition because he reports having chest pain episodes that begun a

month ago, which is a symptom of angina

2. Myocardial Infarction is a heart attack characterized by a lack of blood and oxygen in heart

measles. The condition can lead to heart damage as well as death if not treated. The condition

can be controlled by medication. Myocardial infarction is caused by unhealthy eating habits,

shock, and electrolyte imbalances. The patient may have this condition because, during

percussion, there were fine crackles on the chest and Gallup in the heart

3. Costochondritis-This is a cartilage inflammation that links the rib and sternum. The pain that

causes this disease is the same as that of a heart attack. Costochondritis is also called chest pain,

in many cases, may accompany the pain. The disease has no known cause. Therefore, treatment

is focused on easing patient pain while waiting for the disease to recover on its own. Some of the

symptoms are coughing and chest pain. The patient may have this condition because he has tight

and uncomfortable chest pain, which begun last month.

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References

Anderson, J. L., & Morrow, D. A. (2017). Acute Myocardial Infarction. New England Journal of

Medicine, 376(21), 2053–2064. https://doi.org/10.1056/nejmra1606915

Ong, P., Camici, P. G., Beltrame, J. F., Crea, F., Shimokawa, H., Sechtem, U., Kaski, J. C., &

Bairey Merz, C. N. (2018). International standardization of diagnostic criteria for

microvascular angina. International Journal of Cardiology, 250, 16–20.

https://doi.org/10.1016/j.ijcard.2017.08.068

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Schumann, J. A., Tanuj Sood, & Parente, J. J. (2021, July 10). Costochondritis. Nih.gov;

StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532931/

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