Student Documentation Model Documentation
Objective
Brian is a 58 year old Caucasian male appears to be well-groomed, is pleasant and answers questions clearly and appropriately. He maintains eye contact throughout the exam. He appears in no distress VSS: Bp 146/90 Skin warm to touch, dry, pink and intact. no tenting Heart: S1, s2, s3 and S4 with murmur Carotid pulse: positive Thrill, +3 on right: PMI: displaced laterally, briks and tapping, <3cm Breath sounds: clear in upper lobes, posterior lower lobes with crackles bilaterally. GI: no tenderness, no masses, guarding or distension. BS present at all quads, WNL Liver is palpable and nontender: spleen and kidneys are not palpable Extremties: No edema, Brachial and radial pulse neg for thrill at 2+ popliteal, tibal and dorsalis pedis pulse diminised at 1+. capillary refill less than 3 seconds on extremiteis. EKG: Regular sinus rhythm. No ST changes
• General Survey: 58 year old male is alert and oriented, with clea speech and in no acute distress. • Cardiac: S1, S2, without murmurs or rubs. PMI displaced latera S3 noted at mitral area. • Peripheral Vascular: Right side carotid bruit. JVP 3cm above ste angle. Right carotid pulse with thrill, 3+. Left carotid pulse withou thrill, 2+. Brachial, radial, femoral pulses without thrill, 2+. Poplite tibial, and dorsalis pedis pulses without thrill, 1+. Cap refill less t 3 seconds – 4 extremities. • Respiratory: Breathing is quiet and unlabored. Breath sounds a clear to auscultation in upper lobes and RML. Fine crackles/rales posterior bases of L/R lungs. • Gastrointestinal: Round, soft, non-tender with normoactive bow sounds in 4 quadrants; no abdominal bruits. No tenderness to lig or deep palpation. Tympanic throughout. Liver is 7 cm at the MC and 1 cm below the right costal margin. Spleen and bilateral kidn are not palpable. • Neuro: Alert and oriented x 3, follows commands, moves all extremities. • Skin: Warm, dry, pink, and intact. No tenting. • EKG (interpretation): Regular sinus rhythm. No ST changes.
Assessment
Coronary Artery disease Stable angina Carotid disease pericarditis Aortic aneurysm r/o GERD R/O Sarcodosis
Based on the abnormal findings during cardiovascular and respiratory auscultation, my differentials include coronary artery disease with stable angina; congestive heart failure; carotid disea aortic aneurysm; pericarditis; or GERD.
Plan
Blood work for cardiac enzyme, electrolytes, CBC, Lipid profile, liver function test, cxr, 12 lead EKG Consult with cardiologist Echocardiogram Exercise stress test Dopplers for carotid Patient should be tested with results on labs at the least, and not discharged home. Baby Asa upon arrival Ntiroglycerin if chest pain is present again Warning signs of when to seek medical help like another onset of chest pain, SOB, shoulder or arm pain
Mr. Foster should receive a 12-lead ECG, chest x-ray, and lab workup (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1 lipid profile, and liver function tests) to confirm a diagnosis. He should be referred for an echocardiogram, exercise stress test, a carotid dopplers as well as a consult with a vascular surgeon for carotid evaluation. Mr. Foster should be prescribed diltiazem and diuretic in addition to his daily Lopressor and Lipitor. If needed, a an ACE inhibitor to manage his hypertension and PRN nitroglyce for chest pain that does not subside with rest.
Comments
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