Name:
Section:
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): Troubling chest pain for the past months
History of Present Illness (HPI): Brian Foster is a 58-year-old Caucasian male with a history of hypertension and hyperlipidemia who came to the clinic with a complain of chest pain that started for the past months. He stated that the pain is right in the middle of his chest and does not radiate to his arm, neck, or shoulders. He stated that he doesn’t not have any pain at this moment but rate the pain at a scale of 5/10 during any pain episode. He described the pain as a “tight and uncomfortable”. He stated that the chest pain usually starts during physical activities such as climbing the stairs, working in his yard. He reported that eating does not aggravate the pain, and the chest pain usually lasts for several minutes, and resides or palpitation.
Medications:
Lisinopril 20mg PO Daily,
Atorvastatin 20mg PO daily at bedtime,
Omega 3 Fish Oil 1200mg PO BID
Ibuprofen 400mg as needed for aches and pain
Tylenol 650mg Q6 PRN for mild pain
Allergies:
Codeine— nausea and vomiting
Past Medical History (PMH):
Hypertension (stage II) – diagnosed 1 year ago
Hyperlipidemia – diagnosed 1 year ago
Annual stress test
Recent EKG test
No history of hospitalization
Past Surgical History (PSH): Include dates, indications, and types of operations.
No past surgical histories
Sexual/Reproductive History:
Patient is married with his wife for 27 years, with two children 26 and 19 years old. He is sexually active and denies any erectile dysfunction, sexually transmitted disease, and does not use any kind of contraceptive.
Personal/Social History:
No tobacco use
Denies any use of marijuana, cocaine, heroin, or any other illicit drugs.
He drinks about 2-3 bottles of beer weekly.
He works at civil engineering firm in town and enjoys fishing, sport, does some small electronic repair on the side and usually go to his son’s body building competition. He denies any current exercise routine but used to ride his bicycle around before it was stolen from him. He tries to watch his fat and salt intake. He drinks about two cups a week. He also drink about four or more glasses of water per day and denies soda. He had a recent annual physical with his Primary care physician 3 months ago.
Immunization History:
Patient indicates all vaccines are up to date
Tdap 10/2014, and influenza vaccine is this season
Significant Family History:
Father: hypertension, hyperlipidemia, obesity, died of colon cancer, age 75.
Mother: type 2 diabetes, hypertension, age 80
Brother: died age 24 in motor vehicle accident. Sister: 52–type 2 diabetes, hypertension.
Maternal grandmother: died of breast cancer, age 65.
Paternal grandmother: died of pneumonia, age 78.
Paternal grandfather: died of “old age”, age 85.
Son: healthy, age 26. Daughter: asthma, age 19
Review of Systems:
General: Patient mentioned he has gained approximately 20lbs over the last “couple of years”, He had denied fever, weakness, fatigue, chills, or night sweats. Denies difficulty sleeping.
HEENT: Patient denies recent headache but endorse history of headaches. Denies change in vision, rhinorrhea, tinnitus, sore throat, dysphagia or change in taste.
Neck: Patient denies neck stiffness
Cardiovascular/Peripheral Vascular: Patient verbalized having chest pain that does not radiates to other body. denies crushing, gnawing, or burning pain. No palpitation.
Respiratory: Denies shortness of breath, hemoptysis, and cough
Gastrointestinal: Patient denies nausea, vomiting, constipation, diarrhea, bloating, and heart burn. No abdominal pain
Musculoskeletal: Patient denies gait abnormalities or fractures.
Psychiatric: Patient denies any anxiety, or depression. No suicidal ideations
OBJECTIVE DATA:
Physical Exam:
Vital signs:
BP: 146/90, HR-104, RR- 19, TEMP-36.7, O2- 98, HT- 5’11”, WT- 197 lbs., BMI-27.5
General: Patient is alert and oriented to person, place, time, and situation. He appears called and well groomed. Appropriate appearance for his age. No distress noted or discomfort at this time.
HEENT: No head trauma noted. Normocephalic, PERRLA. No ear discharge or rhinorrhea noted.
Cardiovascular/Peripheral Vascular: S1, S2, S3 noted with gallop sound. No JVD noted. Bruit and thrill with +3 amplitude noted on the right carotid arteries. Equal bilateral pulses in all other arteries. Negative edema noted in all extremities.
Respiratory: Symmetrical chest expansion with adventitious fine crackles noted on the right and left posterior lower lobe. No cough or sputum noted.
Gastrointestinal: Abdomen is soft. Symmetrical and round with normoactive bowel sound in all quadrants. No tenderness noted. Liver is palpable.
Neurological: No anxiety or depression noted
Skin: No tinting skin turgor, Capillary refills is less than 3 seconds in all fingers and toes. No rash or cyanosis noted.
Start here, but use information above
Diagnostic Test/Labs: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses with rationale for each one documented OR ones that were mentioned during the SH assignment.
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.
Name:
Section:
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): Troubling chest pain for the past months
History of Present Illness (HPI): Brian Foster is a 58-year-old Caucasian male with a history of hypertension and hyperlipidemia who came to the clinic with a complain of chest pain that started for the past months. He stated that the pain is right in the middle of his chest and does not radiate to his arm, neck, or shoulders. He stated that he doesn’t not have any pain at this moment but rate the pain at a scale of 5/10 during any pain episode. He described the pain as a “tight and uncomfortable”. He stated that the chest pain usually starts during physical activities such as climbing the stairs, working in his yard. He reported that eating does not aggravate the pain, and the chest pain usually lasts for several minutes, and resides or palpitation.
Medications:
Lisinopril 20mg PO Daily,
Atorvastatin 20mg PO daily at bedtime,
Omega 3 Fish Oil 1200mg PO BID
Ibuprofen 400mg as needed for aches and pain
Tylenol 650mg Q6 PRN for mild pain
Allergies:
Codeine— nausea and vomiting
Past Medical History (PMH):
Hypertension (stage II) – diagnosed 1 year ago
Hyperlipidemia – diagnosed 1 year ago
Annual stress test
Recent EKG test
No history of hospitalization
Past Surgical History (PSH): Include dates, indications, and types of operations.
No past surgical histories
Sexual/Reproductive History:
Patient is married with his wife for 27 years, with two children 26 and 19 years old. He is sexually active and denies any erectile dysfunction, sexually transmitted disease, and does not use any kind of contraceptive.
Personal/Social History:
No tobacco use
Denies any use of marijuana, cocaine, heroin, or any other illicit drugs.
He drinks about 2-3 bottles of beer weekly.
He works at civil engineering firm in town and enjoys fishing, sport, does some small electronic repair on the side and usually go to his son’s body building competition. He denies any current exercise routine but used to ride his bicycle around before it was stolen from him. He tries to watch his fat and salt intake. He drinks about two cups a week. He also drink about four or more glasses of water per day and denies soda. He had a recent annual physical with his Primary care physician 3 months ago.
Immunization History:
Patient indicates all vaccines are up to date
Tdap 10/2014, and influenza vaccine is this season
Significant Family History:
Father: hypertension, hyperlipidemia, obesity, died of colon cancer, age 75.
Mother: type 2 diabetes, hypertension, age 80
Brother: died age 24 in motor vehicle accident. Sister: 52–type 2 diabetes, hypertension.
Maternal grandmother: died of breast cancer, age 65.
Paternal grandmother: died of pneumonia, age 78.
Paternal grandfather: died of “old age”, age 85.
Son: healthy, age 26. Daughter: asthma, age 19
Review of Systems:
General: Patient mentioned he has gained approximately 20lbs over the last “couple of years”, He had denied fever, weakness, fatigue, chills, or night sweats. Denies difficulty sleeping.
HEENT: Patient denies recent headache but endorse history of headaches. Denies change in vision, rhinorrhea, tinnitus, sore throat, dysphagia or change in taste.
Neck: Patient denies neck stiffness
Cardiovascular/Peripheral Vascular: Patient verbalized having chest pain that does not radiates to other body. denies crushing, gnawing, or burning pain. No palpitation.
Respiratory: Denies shortness of breath, hemoptysis, and cough
Gastrointestinal: Patient denies nausea, vomiting, constipation, diarrhea, bloating, and heart burn. No abdominal pain
Musculoskeletal: Patient denies gait abnormalities or fractures.
Psychiatric: Patient denies any anxiety, or depression. No suicidal ideations
OBJECTIVE DATA:
Physical Exam:
Vital signs:
BP: 146/90, HR-104, RR- 19, TEMP-36.7, O2- 98, HT- 5’11”, WT– 197 lbs., BMI-27.5
General: Patient is alert and oriented to person, place, time, and situation. He appears called and well groomed. Appropriate appearance for his age. No distress noted or discomfort at this time.
HEENT: No head trauma noted. Normocephalic, PERRLA. No ear discharge or rhinorrhea noted.
Cardiovascular/Peripheral Vascular: S1, S2, S3 noted with gallop sound. No JVD noted. Bruit and thrill with +3 amplitude noted on the right carotid arteries. Equal bilateral pulses in all other arteries. Negative edema noted in all extremities.
Respiratory: Symmetrical chest expansion with adventitious fine crackles noted on the right and left posterior lower lobe. No cough or sputum noted.
Gastrointestinal: Abdomen is soft. Symmetrical and round with normoactive bowel sound in all quadrants. No tenderness noted. Liver is palpable.
Neurological: No anxiety or depression noted
Skin: No tinting skin turgor, Capillary refills is less than 3 seconds in all fingers and toes. No rash or cyanosis noted.
Start here, but use information above
Diagnostic Test/Labs:
Cardiac magnetic resonance imaging: Findings obtained from a cardiac magnetic resonance imaging test can help the healthcare professional to establish the source of chest pain. The procedure is able to characterize changes in the heart tissues (Ammirati et al., 2021).
Electrocardiogram (ECG): ECG is the key diagnostic test for chest pain. The test is able to tell the functioning of the heart based on the appearance of ST segment. The healthcare provider should observe changes in T-wave inversion, ST-segment elevation, and ST-segment depression (Mayo Clinic, 2021).
Chest x-ray: A chest radiograph can reveal information that can guide the clinician to establish the source of chest pain. A chest x-ray exam enables the healthcare professional to observe the shape, sizes, and structures of the lungs, heart, and blood vessels (Mayo Clinic, 2021).
Blood tests: Changes in cardiac enzymes can best be evaluated by conducting blood tests. When the heart cells are damaged, cardiac enzymes sometimes migrate to the blood. The presence of these enzymes in the blood can tell whether there are issues with the heart or not. (Mayo Clinic, 2021).
ASSESSMENT:
Acute myocarditis (priority diagnosis)
Acute myocarditis is the priority diagnosis for the patient’s symptoms. This condition is normally characterized by chest pain that is located at the middle of the chest. In rare cases, chest pain due to acute myocarditis can diffuse to nearby organs. The pain is normally exacerbated with physical activity and it lasts for several minutes whenever it occurs. EKG results show depressions and elevations of the ST-segments (Ammirati et al., 2021).
Differential Diagnoses
- Unstable angina: Symptoms of unstable angina often mimic those of acute myocarditis. However, as opposed to acute myocarditis, patients with unstable angina normally experience pain even at rest (Baruah & Hartley, 2020). As reported by the patient, he does not experience pain at the moment meaning that it comes and goes.
- Pneumonia: In addition to persistent chest pain, individuals with pneumonia normally present with respiratory issues such as breathing difficulties, cough, and wheezing (Kaysin & Viera, 2016). The patient denies shortness of breath, hemoptysis, and cough. Additionally, no cough or sputum has been noted. These findings show that pneumonia is unlikely.
- Pulmonary embolism: Patients with pulmonary embolism usually present with chest that is concentrated at the middle of the chest. However, the pain often radiates to the right or left sides of the chest. Other clinical manifestations that are usually seen in patients with pulmonary embolism but not in individuals with acute myocarditis include; fatigue, swollen legs, syncope, and hemoptysis (Li et al., 2018). The absence of these symptoms in the patient rule out the possibility of pulmonary embolism.
References
Ammirati, E., Veronese, G., Bottiroli, M., Wang, D. W., Cipriani, M., Garascia, A., Pedrotti, P., Adler, E. D., & Frigerio, M. (2021). Update on acute myocarditis. Trends in Cardiovascular Medicine, 31(6), 370–379. https://doi.org/10.1016/j.tcm.2020.05.008
Baruah, R. & Hartley, A. (2020). Unstable angina. BMJ Best Practice. https://bestpractice.bmj.com/topics/en-gb/3000100
Kaysin, A., & Viera, A. (2016). Community-acquired pneumonia in adults: Diagnosis and management. American Family Physician, 94(9), 698-706. https://www.aafp.org/afp/2016/1101/p698.html
Li, W., Chen, C., Chen, M., Xin, T., & Gao, P. (2018). Pulmonary embolism presenting with itinerant chest pain and migratory pleural effusion: A case report. Medicine, 97(22), e10944. https://doi.org/10.1097/MD.0000000000010944
Mayo Clinic. (2021). Chest pain. https://www.mayoclinic.org/diseases-conditions/chest-pain/diagnosis-treatment/drc-20370842