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Document: Provider Notes

– NURS 6512
)

Name:

(
Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. When you are ready to submit your documentation, ‘Save As’ with this title format: “[LastName_FirstName] Shadow Health Documentation Template – Focused Exam_Chest_Pain – NURS 6512”
)Focused Exam: Chest Pain

(
Chief Complaint (CC):

” I have been having some troubling chest pain in my chest now and then for the past month.”

History of
Present Illness:
Mr. Foster is a 58-year- male who presents to the clinic stating
that he has been experiencing

chest pain with exertion such as overeating and doing yard work.

He states,

I feel it mostly in the middle of my chest over my heart.

He describe
s
the pain as “tight and uncomfortable” with a pain level of 5/10, non

radiating, lasting for a few minutes, and goes away when at rest. The most recent chest pain episode was a week ago when he had to use the stairs at work because the elevator was broken. At first, he thought the chest pain was a heartburn that will go away but after the last epi
sode
he became concern wanted his heart checked.

He denies experiencing cramps in the legs, shortness of breath, heartburn and constipation.
Medications:
Lisinopril (Prinivil) 20mg PO daily
Atorvastatin (Lipitor) 20mg PO daily at bedtime, last dose yesterday (hyperlipidemia).
Omega-3 Fish Oil 1200mg PO BID last dose 8am (OTC supplement).
Allergies:

Codeine – Nausea and vomiting
Immunization:
Tdap 10/24
Influenza vaccine this season
Medical History:
Hypertension – Stage 11, diagnosed 1year ago
Hyperlipidemia – diagnosed 1year ago
No surgical history
Last EKG at annual physical 3 months ago, results were normal
Annual stress test, last 4 months ago and the results were normal.
Family History:
Father:

H
ypertension, h
yperlipidemia, obesity, died of colon cancer, age 75
Mother:
type 2 diabetes, hypertension at age 80.
Brother:
Died at age 24 in a motor vehicle accident
S
ister: Type 2 diabetes, hypertension, age 52.
T
he patient present to the clinic stating, ” he reports that he has been experiencing chest pain with exertion such as overeating and doing yard work. He states, I feel it mostly in the middle of my chest over my heart.” He describe
s
the pain as “tight and uncomfortable” with a pain level of 5/10, non

radiating, lasting for a few minutes, and goes away when at rest. The most recent chest pain episode was a week ago when he had to use the stairs at work because the elevator was broken. At first, he thought the chest pain was a heartburn that will go away but after the last epi
sode
he became concern wanted his heart checked.

He denies experiencing cramps in the legs, shortness of breath, heartburn and constipation.
)Subjective

(
Maternal Grandmother:
Died of breast cancer, age 65.
Maternal Grandfather:
Died of heart attack, age 54.
Paternal Grandmother:
died of pneumonia, age
78.
Paternal Grandfather:
Died of “old age”, age 85.
Son:
Healthy, age 26
Daughter:
Asthma, age 19.
Social History:
No past or present tobacco use
Report drinking 2-3 alcoholic beverages (beer) per week.
Denies use of marijuana, cocaine, heroin, or other illicit drugs.
Objective
Vital signs: B/P 104/88; Temp: 36.7C; Pulse: 104; Resp: 19; O2 Sat: 98
Weight: 197lbs
Height: 5’11”
The patient is a 58

year

old male, alert and oriented, with clear speech and no acute distress. Cardiac: S1, S2, and S3 noted at mitral area with gallops. PMI is displaced laterally. Right carotid bruit is noted, and right carotid pulse with thrill, 3+. JVP is 3cm above sternal angle. Left carotid pulse without thrill, 2+ is also noted. Also brachial, radial and femoral pulses without thrill, 2+. the popliteal, tibial, and dorsalis pedal pulses without thrill, 1+ was noted also. The bilateral upper and lower extremities capillary refill was less than 3 seconds. Respiratory: Breathing is unlabored and quiet. Breathing sounds clear on auscultation in the upper lobes and RLM. Fine crackles are heard on the posterior left/right bases of the lungs. Gastrointestinal: Abdomen is round, soft, non-tender with bowel sounds present in all four quadrants. No abdominal tenderness to light and deep palpitation and no bruits noted. The abdomen is tympanic throughout, the liver is 7cm at the MCL, and 1cm below the right coastal margin. The spleen and kidneys are non-palpable. Skin: Skin is warm, dry and intact with no tinting. Neuro: Patient is alert and oriented X3, follows commands, and is able to move both upper and lower extremities. EKG: The result or interpretation indicates Regular sinus rhythm, No ST changes.
)

(
Assessment
From the cardiovascular and respiratory data findings during the assessment, my differential or diagnose include the following: Congestive Heart Failure (CHF), GERD, Pericarditis, or Carotid disease.
Plan
Mr. Foster should have the following lab tests done; CMP, BNP, CBC, A1c, Hgb, cardiac enzymes, Liver function test and lipid profile tests to confirm his diagnosis. A chest x-ray and a 12-lead ECG should also be performed. A referral to for an echocardiogram, stress test, and carotid doppler should be given to Mr. Foster. He should keep a log of his blood pressure and follow up with his cardiologist. Education on exercising and a healthy diet should be provided. An ACE inhibitor to manage his high blood pressure, and PRN nitroglycerin to manage his chest pain should in case the pain does not stop while resting should be added to his medications.
)Assessment

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