Assessing the Heart, Lungs, and Peripheral Vascular System Essay

 Assessing the Heart, Lungs, and Peripheral Vascular System Essay

 Assessing the Heart, Lungs, and Peripheral Vascular System Essay

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

SUBJECTIVE DATA:

Chief Complaint (CC): I have been experiencing chest pains in the last three months

History of Present Illness (HPI): Brian Foster is a 58-year-old patient that came to the hospital with complaints of having some persistent chest pain for the past one month. The patient reported a history of hypertension and hyperlipidemia. The patient’s description of the chest pain was that it is non-radiating, tight, and uncomfortable. He also reported that it originates from the midsternal region. He rated it at 5 out of 10 in the pain rating scale. Foster also reported that the chest pain has occurred three times over the past month, lasting a few minutes. He experienced the last chest pain attack in the last three days. The client noted that he first experienced chest pain when he was engaged in yard work, followed by when he was walking up four stairs to bed, and the third occurrence being when he was out for a dinner with his spouse. He reported that chest pain worsen with activity and rest relieves it. He did not seek medical care after the first attacks since he never thought that it was a serious health issue. However, his concerns grew when he experienced three episodes of chest pains within a month. Foster reported that his last physical examination was about a year ago, which was his first ever checkup. His diet comprised mainly of some sandwiches, vegetable, and grilled meat. He also reports that he often has fast foods for his lunch. He denied any fatigue, wheezing, cough, vomiting, back pain, diarrhea, and nausea.

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Medications: The patient is currently on several medications. They include Metoprolol 100 mg PO daily, Lisinopril 20 mg PO daily, Atorvastatin 20 mg PO daily at bedtime, Omega-3 Fish Oil 1200 mg PO BID, over-the-counter Tylenol as needed for pain and aches 3-4 times a month, and over the counter ibuprofen as needed for pain and aches 3-4 times a month.  

Allergies: Foster reported that he experiences nausea and vomiting whenever he uses Codeine.

Past Medical History (PMH): Foster was diagnosed with hypertension stage II a year ago. He was also diagnosed with hyperlipidemia a year ago. He denied any surgical history or hospitalization.

Past Surgical History (PSH): Foster denied any history of surgeries.

Sexual/Reproductive History: He has two children

Personal/Social History: Foster is an engineer with two children aged 26 and 19 years. He speaks fluent English. He has no history of smoking. He reported that he drinks 2-3 beers during the weekends. He denied any history of using cocaine, marijuana, heroine or any other illicit drug. His last physician visit was three months ago. He rarely engages in active physical activities. He reported that is conscious with his dietary habits.

Immunization History: The patient reported that his Tdap vaccination was in October 2014 while his influenza vaccine was this season.

Significant Family History: Foster reported that his father was diagnosed with obesity, hypertension, and hyperlipidemia. He died due to colon cancer at 75 years. His mother who is 80 years old is hypertensive and diabetic. His brother died when he was 24 years due to a motor vehicle accident. Foster’s sister, 52, has type 2 diabetes mellitus and hypertension. His maternal grandmother died due to breast cancer when she was 65 years while his maternal grandfather died at 54 years because of heart attack. Foster’s paternal grandmother died at 78 from pneumonia while his paternal grandfather died at 85 years due to old age. He has a son, 26 years old who is healthy and an asthmatic daughter aged 19 years old.

Review of Systems:

General: The patient appeared alert, oriented, and of appropriate weight for his age. He denied chest pain during the assessment as well as headache, syncope or ever.

                Cardiovascular/Peripheral Vascular: The patient reported a history of hypertension. He denied palpitations, jugular venous distention, and edema. He reported that an EKG performed three months ago was normal.

                Respiratory: The patient denied cough, wheezing, and shortness of breath.

                Gastrointestinal: The patient denied nausea, diarrhea, vomiting, and stomach ache.

                Musculoskeletal: The patient denied joint or bone pain, fractures, and difficulty in walking

                Psychiatric: The patient denied depression or any other psychiatric condition

OBJECTIVE DATA:

                Physical Exam:

Vital signs: BP 146/90, pulse 104, SPO2 98%, respiratory rate 19, weight 197 lbs, Temperature 36.7, Height 5’11

General: The patient is alert, oriented, and has clear speech. He is comfortably sited, responsive to questions, and demonstrates no signs of acute distress.  

              Cardiovascular/Peripheral Vascular: S1 and S2 heart sounds without friction rubs and murmurs heard. S3 heard at the mitral region. Absence of fluid retention. There is also the absence of jugular venous distention, left jugular pressure is 3 cm above the sternal angle. No bruit heard over the left carotid. A three of 3+ heard on the right carotid. Femoral and brachial pulses are +2 with a capillary refill of less than 3 seconds in all the extremities.

Respiratory: The patient demonstrates quiet, unlabored breathing with clear breathing sounds on auscultation. Fine crackles heard on the posterior bases of both right and left lungs.

Gastrointestinal: The abdomen is soft and round with normal bowel sounds in the four quadrants. Absence of abdominal bruits, tenderness, and presence of tympany. Absence of organomegaly on palpation.

Musculoskeletal: The patient can move the extremities with ease

Neurological: The patient is alert, oriented, with intact cranial nerves.

Skin: Absence of bruises, rashes, and skin breakdown

Diagnostic Test/Labs: EKG was done. It revealed normal sinus rhythm and absence of ST segment elevation

ASSESSMENT:

Angina pectoris: The client’s primary diagnosis is angina pectoris. Angina pectoris is chest pain that arises from reduced blood flow and oxygenation to heart muscles or tissues. Patients experience chest pain whenever they engage in activities that increase oxygen demand such as exercising or stress. EKG findings in angina pectoris are normal (Webb & Collins, 2021). Foster reports experiencing chest pain with exercise and relieved by rest. In addition, the EKG findings are normal, hence, angina pectoris being the primary diagnosis.

Heart failure: Heart failure is the client’s secondary diagnosis. Heart failure arises from the reduced pumping ability of the heart. The assessment findings revealed S3 heart sound during the assessment, which demonstrates that the patient is developing congestive heart failure. S3 heart sound represents a reduction in ventricular filling during diastole (Malik et al., 2022). Therefore, additional interventions should be undertaken to rule out and manage heart failure.

Coronary artery disease: coronary artery disease is the third diagnosis that should be considered for the patient. Signs of coronary artery disease include bruit being heard over the arteries during auscultation. Patients present with symptoms such as chest pain, dyspnea, fatigue, and activity intolerance (Malakar et al., 2019). Foster has some of these symptoms, hence, coronary artery disease being part of the diagnoses.

References

Malakar, A. Kr., Choudhury, D., Halder, B., Paul, P., Uddin, A., & Chakraborty, S. (2019). A review on coronary artery disease, its risk factors, and therapeutics. Journal of Cellular Physiology, 234(10), 16812–16823. https://doi.org/10.1002/jcp.28350

Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2022). Congestive Heart Failure. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK430873/

Webb, C. M., & Collins, P. (2021). Medical management of anginal symptoms in women with stable angina pectoris: A systematic review of randomised controlled trials. International Journal of Cardiology, 341, 1–8. https://doi.org/10.1016/j.ijcard.2021.07.018

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 Assessing the Heart, Lungs, and Peripheral Vascular System

DCE: Chest pain documentation – BRIAN FOSTER

• Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
• Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
• Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
• Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
• Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
• Consider what history would be necessary to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?