Week 7 assessment

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Week 7

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:

1. Location

2. Quality

3. Quantity or severity

4. Timing, including onset, duration, and frequency

5. Setting in which it occurs

6. Factors that have aggravated or relieved the symptom

7. Associated manifestations

Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdp, Flu, pneumonia, etc.

Significant Family History: Include history of parents, Grandparents, siblings, and children.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

Cardiovascular/Peripheral Vascular:

Respiratory:

Gastrointestinal:

Musculoskeletal:

Psychiatric:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

Physical Exam:


Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

Cardiovascular/Peripheral Vascular: Always include the heart in your PE.

Respiratory: Always include this in your PE.

Gastrointestinal:

Musculoskeletal:

Neurological:

Skin:

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.

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Focused Exam: Chest Pain Results | Completed
Advanced Health Assessment – January 2020, nur634

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Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Mr. Foster is a pleasant 58 years old caucasian man who presented
to the clinic with chief complaints of intermittent chest pain that has
been going on for the past month. There is no evidence of acute
distress at this time and he currently denies chest pain. He states
that his chest pain occured at least three times this month. He states
“I feel it mostly in the middle of my chest. over my heart.” He states
that pain severity at its worst is 5/10, non-radiating, and usually goes
after a couple of minutes. He describes the pain as “mostly feels
tight and uncomfortable right in the middle of the chest.” He further
states “the pain seems to start when I’m doing something physical
and subsides a little bit with rest.” He denies taking any medication
to relieve his chest pain. He reports history of hypertension and
hyperlipidemia and takes Atorvastatin 20mg daily and fish oil for
cholesterol and metoprolol 100mg daily for his hypertension. He
reports that he has not been checking his blood pressure at home
and only gets it checked during clinic visits. He states that his last
physical was about three months ago. Reports ocassional alcohol
consumption. Denies smoking and substance abuse. He denies
shortness of breath, fever or chills and any abdominal dsicomfort. He
denies history of blood clot and bleeding. He states that his mom
died of heart attack.

Pt. reports: “I have been having some troubling chest pain in my
chest now and then for the past month.” Experiencing periodic chest
pain with exertion such as yard work, as well as with overeating.
Points to midsternum as location. Describes pain as “tight and
uncomfortable” upon movement or exertion. Mentioned an episode
upon going up the stairs to bed. Most recent episode was three days
ago after eating a large restaurant dinner. Denies radiation. Pain lasts
for “a few” minutes and goes away when he rests. States “It has
never gotten ‘really bad'” so he didn’t think it was an emergency, but
is concerned after three episodes in one month and wants his heart
checked out. Last physical was 1 year ago but says he hadn’t been
checked out for several years prior. His regular diet includes grilled
meat, some sandwiches, and vegetables. Reports grilling between 4-
5 times a week, usually red meat. Has fast food for lunch on busy
days. 1-2 cups of coffee a day. Denies coughing, shortness of
breath, indigestion, heartburn, jaw pain, fatigue, dizziness,
weakness, nausea, vomiting, and diarrhea. Denies chest pain at time
of interview. No history of anxiety or depression.

• General Survey: Alert and oriented, with clear speech. Sitting
comfortably in no acute distress.

• Cardiac: S1, S2, without murmurs or rubs. S3 noted at mitral area.

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Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Vitals Document: Provider Notes

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Objective

General Survey: 58 years old male patient is alert and oriented, with
clear speech and no acute distress. V/s BP 146/90, HR 104,
respiration 19, SpO2 98% on room air and temperatire 36.7C. Facial
expression symmetrical.
Cardiac: S1 S2 wit S3 noted at mitral area, without murmurs. No
jugular vein distention.
Peripheral Vascular: Capillary refill less than 3 seconds in all
extremities. Right carotid pulse with thrill, 3+ and left carotid pulse
without thrill, 2+. PMI displaced laterally, brisk and tapping, less than
3 cm. R/L brachial pulses no thrill, 2+. R/L radial pulses no thrill, 2+.
R/L femoral pulses no thrill, 2+. R/L popliteal pulses no thrill 1+. R/L
tibial pulses no thrill 1+. R/L dorsalis pedis pulses no thrill 1+. All
extremities are dry and warm to touch. No edema, varicosities and
stasis noted.
Respiratory: Breathing is quiet and unlabored. Chest expansion
symmetrical. Breath sounds are clear to ausculation in upper lobes.
Fine crackles on pesterior bases of both lungs.
Gastrointestinal: Round, soft, nontender with normoactive bowel
sounds in all four quadrants, no abnormal bruits. No tenderness to
palpation. Tympanic throughout. Liver is 7cm in the midclavicular
line.
Neuro: Alert and oriented, follows commands
EKG: NSR with no ST changes

No swelling or fluid retention present.

• Peripheral Vascular: No JVD present. JVP 3 cm above sternal
angle. Left carotid no bruit. Right side carotid bruit. Right carotid
pulse with thrill, 3+. Brachial, radial, femoral pulses without thrill, 2+.
Popliteal, tibial, and dorsalis pedis pulses without thrill, 1+. Cap refill
less than 3 seconds in all 4 extremities.

• Respiratory: Breathing is quiet and unlabored. Breath sounds are
clear to auscultation in upper lobes and RML. Fine crackles in
posterior bases of L/R lungs.

• Gastrointestinal: Round, soft, non-tender with normoactive bowel
sounds in all quadrants; no abdominal bruits. No tenderness to light
or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL
and 1 cm below the right costal margin. Spleen and bilateral kidneys
are not palpable.

• Neuro: Alert and oriented x 3, follows commands, moves all
extremities. Gross cranial nerves 2-12 bilaterally and grossly intact.

• Skin: Warm, dry, pink, and intact. No tenting and no sweating.

• Musculoskeletal: Moves all extremities.

• Psych: Normal affect, cooperative, good eye contact.

• EKG (interpretation): Regular sinus rhythm. No ST changes.

• Gastrointestinal: Round, soft, non-tender with normoactive bowel
sounds in 4 quadrants; no abdominal bruits. No tenderness to light
or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL
and 1 cm below the right costal margin. Spleen and bilateral kidneys
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 with stable angina. Possible congestive
heart failure, carotid disease or GERD.

Based on the abnormal findings during cardiovascular and
respiratory auscultation, my differentials include coronary artery
disease with stable angina; congestive heart failure; carotid disease;
aortic aneurysm; pericarditis; or GERD.

Plan

1. Since Mr. Foster’s BP is not yet controlled, I will titrate his
Lopressor and transition to ACE inhibitor. Will also refer to
Cardiologist for start of diuretic therapy, PRN nitroglycerin for chest
pain, echocardiogram and stress test. May need an additional
consult with a vascular surgeon for carotid evaluation.
2. Cxray, lab workup including cardiac enzyme, electrolyte, CBC,
BMP, CMP, Hgb, A1C, lipid profile, and liver function test.
3. Educate patient regarding exercise, diet and lifestyle modification.
Educate Mr. Foster to seek immediate medical attention if chest pain
returns and gets worse.
7. Return to clinic in 5-7 days for follow-up.

Mr. Foster should receive a 12-lead ECG, chest x-ray, and lab
workup (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1C,
lipid profile, and liver function tests) to confirm a diagnosis. He
should be referred for an echocardiogram, exercise stress test, and
carotid dopplers as well as a consult with a vascular surgeon for
carotid evaluation. Mr. Foster should be prescribed diltiazem and a
diuretic in addition to his daily Lopressor and Lipitor. If needed, add
an ACE inhibitor to manage his hypertension and PRN nitroglycerin
for chest pain that does not subside with rest.

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

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Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is detailed and organized and includes:
Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.

You should list these in bullet format and document the systems in order from head to toe.—

Objective Documentation in Provider Notes – this is to be completed in Shadow Health

Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.
You only need to examine the systems that are pertinent to the CC, HPI, and History.

Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).–

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