Fluent Essays

Instructions: 1.Complete the assignment using the provided template ( see attachment - Week 7_Template)  2. Use the information provided in word documents (3)  and PDF documents (3) to complete the assignment - Brian Foster - Documents and transcripts. 3.  List your priority diagnosis. For each priority diagnosis, list at least 5 differential diagnoses, each of which must be supported with evidence and guidelines.   4. At least 5 references. Established chief complaint Reports chest pain Asked about onset and duration of chest pain Reports chest pain started about five minutes ago Reports chest pain has been constant since it began Reports sitting in bed when pain began Asked to rate chest pain on a scale Reports current pain is 6/10 Asked about on characteristics of the pain Describes pain as tight and uncomfortable Denies crushing pain Denies gnawing or tearing pain Denies burning pain Asked about location of the pain Reports pain location is in middle of the chest Reports slight pain in left shoulder Denies arm pain Denies back pain Denies jaw pain Denies neck pain Asked about pain triggers Reports pain is aggravated by movement Asked about stress and anxiety Reports generally low stress lifestyle Denies history of anxiety Denies history of panic attacks Asked relevant health history Reports high blood pressure Reports high cholesterol Denies history of pulmonary embolism Denies history of angina Denies history of rheumatic fever Denies history of heart murmur Followed up on high blood pressure treatment Reports taking high blood pressure medication Reports high blood pressure medication is Lisinopril High blood pressure medication dose is 20mg High blood pressure medication is taken once daily Followed up on high cholesterol treatment Reports taking high cholesterol medication Reports high cholesterol medication is Atorvastatin (Lipitor) Reports high cholesterol medication dose is 20mg Reports high cholesterol medication is taken once daily Asked history of cardiac tests Reports recent EKG test Reports annual stress test Asked about results of cardiac tests Reports belief that EKG was normal Reports belief that stress test was normal Asked about substance use Denies illicit drug use Denies tobacco use Reports moderate alcohol consumption Followed up on alcohol consumption Reports drinking only on weekends Reports drinking 2-4 alcoholic drinks per week Reports 2-3 drinks in a single sitting Asked about exercise Denies having a regular exercise routine Asked about most recent meal Reports most recent meal was previous night at 8 p.m Reports meal consisted of buffalo wings Asked about typical diet Reports typical breakfast is granola bar and instant breakfast shake Reports typical lunch is turkey sub Reports typical dinner is grilled meat and vegetables Denies moderating salt intake Asked about review of cardiovascular system Denies palpitations Denies swelling Denies circulation problems Denies blood clots Denies easy bleeding Denies easy bruising Asked about constitutional health Denies fever Denies chills Denies fatigue Denies sleep issues Denies recent weight changes Denies night sweats Denies dizziness or lightheadedness Asked about review of respiratory system Denies cough Denies shortness of breath while lying down Denies blue skin Asked about throat problems Denies sore throat Denies difficulty swallowing Asked about review of gastrointestinal system Denies diarrhea Denies constipation Denies flatus Denies bloating Denies heartburn or GERD Reports earlier nausea Denies vomiting Asked relevant family history Reports family history of heart attack Denies family history of stroke Denies family history of pulmonary embolism Established chief complaint Reports chest pain Asked about onset and duratio n of chest pain Reports chest pain started about five minutes ago Reports chest pain has been constant since it began Reports sitting in bed when pain began Asked to rate chest pain on a scale Reports current pain is 6/10 Asked about on characteristics of the pain Describes pain as tight and uncomfortable Denies crushing pain Denies gnawing or tearing pain Denies burning pain Asked about location of the pain Reports pain location is in middle of the chest Reports slight pain in left shoulder Denies arm pain Denies back pain Denies jaw pain Denies neck pain Asked about pain triggers Reports pain is aggravated by movement Asked about stress and anxiety Reports generally low stress lifestyle Denies history of anxiety Denies history of panic attacks Asked relevant health history Reports high blood pressure Reports high cholesterol Denies history of pulmonary embolism Denies history of angina Denies history of rheumatic fever Denies history of heart murmur Followed up on high blood pressure treatment Reports taking high blood pressure medication Reports high blood pressure medication is Lisinopril High blood pressure medication dose is 20mg High blood pressure medication is taken once daily Followed up on high cholesterol treatment Established chief complaint Reports chest pain Asked about onset and duration of chest pain Reports chest pain started about five minutes ago Reports chest pain has been constant since it began Reports sitting in bed when pain began Asked to rate chest pain on a scale Reports current pain is 6/10 Asked about on characteristics of the pain Describes pain as tight and uncomfortable Denies crushing pain Denies gnawing or tearing pain Denies burning pain Asked about location of the pain Reports pain location is in middle of the chest Reports slight pain in left shoulder Denies arm pain Denies back pain Denies jaw pain Denies neck pain Asked about pain triggers Reports pain is aggravated by movement Asked about stress and anxiety Reports generally low stress lifestyle Denies history of anxiety Denies history of panic attacks Asked relevant health history Reports high blood pressure Reports high cholesterol Denies history of pulmonary embolism Denies history of angina Denies history of rheumatic fever Denies history of heart murmur Followed up on high blood pressure treatment Reports taking high blood pressure medication Reports high blood pressure medication is Lisinopril High blood pressure medication dose is 20mg High blood pressure medication is taken once daily Followed up on high cholesterol treatment Name: Section: 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 5 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. © 2021 Walden University © 2021 Walden University Name: Section: 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, an d 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. Allerg ies: 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. © 2021 Walden University Name: Section: 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. Focus of Assessment: Brian Foster is a fifty-eight-year-old Caucasian male that has come in to be evaluated for three episodes of intermittent chest pain that has occurred over the last month. This is the first time he has sought out medical evaluation. The objective is to discern the cause of the intermittent chest pain by using sound clinical reasoning. Clinical reasoning can only be developed through experience. Each examination of patient brings about a new learning opportunity to further build clinical expertise.  Subjective Findings             Brian comes to the clinic complaining of three episodes of chest pain in the last month. Two episodes were related to increased activity. The first during heavy yard work and the second walking up four flights of stairs at work. Over eating at his wife’s birthday dinner precipitated the third episode three days ago. During each event, he reports the pain came on suddenly, was in the center of his chest but did not radiate. He describes the pain as a feeling of tightness and being uncomfortable. Pain was reported as five on a numerical pain scale of zero to ten, and lasted only for a few minutes. He denies shortness of breath, syncope, cough, numbness, tingling, nausea, diaphoresis, or heart burn during chest pain events. Resting minimally helps to relieve the pain and thus far he has not taken any medication related to the chest pain. He feels the pain has not been severe enough to consider it an emergency, but does want to have his heart checked out. He currently denies having chest pain and reports his pain as zero.  Medical History             Brian reports he has a history of hypertension and hyperlipidemia. Prescription medications are Lopressor 100mg daily and Lipitor 20 mg daily at bedtime. For occasional body or headaches, he uses Tylenol or Advil and follows the direction on the bottle. 1200mg of Fish oil is the only supplement he currently takes.  Brian reports an allergy to codeine that causes nausea but no other known allergies. He denies being treated for chest pain in the past, coronary artery disease, diabetes, or respiratory issues. Last year during his annual exam, a twelve-lead electrocardiogram was performed and reported as normal. Social History Brian is married with one daughter and reports a low stress life at home and work. He does not exercise daily but expressed interest in riding a bike once he is feeling better. Breakfast consists of a granola bar or instant breakfast packet. Occasionally he has a large breakfast consisting of eggs, potatoes and bacon. Lunch is typically a turkey sub or salad. He often grills meat and vegetables for dinner. Brian drinks two cups of coffee each day and one liter of water. He reports no illicit drug use and does not smoke. On the weekends, he drinks two or three beers over the weekend.  Review of systems In general, he denies fever, fatigue, weight loss, palpitations, syncope, or night sweats. No cardiovascular history of murmur, edema, or coagulopathy. Respiratory history negative for productive or nonproductive cough or shortness of breath. No gastrointestinal history of heartburn, nausea, vomiting, GERD, constipation or diarrhea. No Musculoskeletal issues of back pain, arthritis, or recent injuries.  Family History             Father had a history of hypertension and hyperlipidemia. Grandfather passed away form myocardial infarction in mid-fifties. Mother and sister both have diabetes. No family history of pulmonary embolism, stroke, or respiratory issues.  Objective Findings             Brian is a fifty-eight-year-old male alert and oriented to person, place, and time. He makes eye contact throughout visit and is in no distress. He is cooperative to both interview and physical exam. Vital signs are as follows, BP: Right arm 146/90   Left arm 146/88   Pulse: 104 O2Sat: 98\%   Resp. rate: 19 Temp. 36.7. Blood Pressure, heart rate elevated despite Lopressor.  Systems Cardiovascular Heart auscultated S1, S2, and an S3 gallop noted at the 5th left intercostal space at the midclavicular line. Preferably, the patient should be in the left lateral decubitus position for most reliable exam findings. PMI at the fifth intercostal space midclavicular line snapping and brisk but noted lateral shift per palpation. Twelve lead electrocardiogram interpretation, regular rhythm no ST changes.  Peripheral vascular Right carotid artery bruit noted per auscultation and thrill noted at 3+ per palpation. Left carotid artery no bruit auscultated. No thrill appreciated amplitude 2+ as expected per palpation. JVP three centimeters above sternal angel per inspection normal finding. Brachial, radial, femoral pulses without thrill, expected amplitude 2+ per palpation. Popliteal, tibial, and dorsalis pedis without thrill per palpation. However, amplitude was less than expected at 1+ per palpation. Capillary refill less than three seconds’ times four extremities. No edema noted throughout exam both to visual inspection and palpation. Respiratory Patient breathing unlabored. Vesicular breath sounds auscultated right and left upper lobes, right middle lobe both anterior and posteriorly. Fine crackles auscultated posteriorly in right and left lower lobes.  Skin Skin warm, pink, and dry per observation. No tenting per palpation. No edema present.  Gastrointestinal Stomach soft without tenderness to light or deep palpation. Bowel sounds normoactive times four quadrants per auscultation. No abdominal aortic artery bruit appreciated on auscultation. Unable to palpate liver, spleen, or bilateral kidneys. Tympanic throughout abdomen per percussion. The liver is one centimeter below the right costal margin per percussion.  Differential Diagnosis             Identifying the attributes of each symptom and pursuing related details are fundamental to recognizing patterns of disease and to generating the differential diagnosis (Bickley, L. S., 2013). Brian is not having what appear to be an emergent episode of chest pain. If he were, differential diagnosis would be myocardial infarction, aortic dissection, acute coronary insufficiency, or pulmonary embolism. He has experienced three episodes of pain over the last month and reports no pain during this visit. Differential diagnosis for nonemergent chest pain will be explored here.  Potential diagnosis based on the patients’ clinical findings are coronary artery disease with stable angina, aortic stenosis, pericarditis, or esophagitis.  Esophagitis Spasms of the esophagus can mimic angina. Patients usually report that the symptoms are worse after eating spicy foods, large meals, or if they lie down after eating (Dains, J., Baumann, L., & Scheibel, P., 2011).   On exam, patients may have tenderness in the epigastric area during palpation. Brian reports one incident of chest pain related to a large meal. He did mention however, he felt that the episode was coming on before he started to eat. No other issues related to heart burn, nausea or indigestion were reported. This is unlikely the cause of his chest pain.  Pericarditis             Associated pain is described as sharp focused in the center of the chest and radiates to the back. Risk factors include recent viral or bacterial infection, MI, uremia, and history of autoimmune disease (Dains & Baumann, 2011). Brian denied any recent illnesses or fever. His chest pain does not radiate to his back but stays only in the middle of his chest. On exam, no pericardial friction rub was auscultated. This is unlikely the cause of Brian’s pain.            Aortic stenosis              Some causes of aortic stenosis include rheumatic fever, congenital anomalies, or calcification of the aortic valve leaflets. One of the early symptoms is angina, which is usually stable and exertion-related. A more serious and later condition is syncope, again associated with exercise. Additional heart sounds, such as an S4, may be heard secondary to hypertrophy of the left ventricle which is caused by the greatly increased work required to pump blood through the stenotic valve (Narayan, P., & Khetan, A. 2015). Brian denies a history of rheumatic heart disease or syncope, however has an S4 gallop per auscultation. Typically, this type of murmur is best heard at the second right intercostal space with the patient leaning forward (Dains, J., Baumann, L., & Scheibel, P., 2011). It was not possible to ask the patient to lean forward during this assessment. Aortic stenosis is a viable diagnosis for this patient. An echocardiogram would be required to confirm this diagnosis.  Coronary artery disease and stable angina Brian has several positive risk factors for coronary artery disease. He is a male over forty-five with a history of hypertension and hyperlipidemia. He also has a positive family history of myocardial infarction and hyperlipidemia. Atherosclerotic changes in his arteries are the likely culprit of his symptoms. The resulting plaque buildup narrows the blood flow causing angina which is commonly caused by coronary artery disease.  Stable angina refers to chest pain typically described as substernal chest pressure or heaviness (Dains & Baumann, 2011). Brian reports his pain as a tightness in the middle of his chest, however the pain does not radiate. Angina is brought on by increased activity or exertion and lasts for five to ten minutes. It is usually relieved by rest and or medication. Brian reported his pain lasted only a few minutes and felt better with rest. Per auscultation, a bruit is present in the right carotid artery. Per palpation, bilateral lower extremity pulse pressure is 1+ a lower than expected.  The findings may be a result of atherosclerotic changes and result in peripheral vascular disease. Many patients with coronary artery disease (CAD) are affected by concomitant significant peripheral atherosclerosis (Sannino, A., Losi, M., Giugliano, G., Canciello, G., Toscano, E., Giamundo, A., & ... Esposito, G., 2015).  Treatment Plan Diagnostics Brian will require further diagnostic testing before a diagnosis can be made. A repeat ECG is necessary as it may pick up an abnormality not previously found. Evidence of ischemia is not always obvious on an ECG even when the patient is reporting anginal pain (Dains & Baumann, 2011). Laboratory studies including CK-MB, Troponin-I, CBC, BMP, Lipid panel, LFT’s, and HgbA1c. Even though he does not currently have chest pain, if there has been any damage it could possibly still be picked up. CK-MB levels peak twenty-four hours after an MI, but Tropin-I levels will remain elevated seven to ten days after an MI.  Brian has a history of hyperlipidemia and has been taking Lipitor and its effectiveness needs to be reevaluated.   A strong family history for diabetes necessitates a HgbA1c level. An echocardiogram to evaluate his heart function including the four heart valves. This information will determine if he has aortic stenosis. An exercise stress test will determine myocardial function related to blood flow thus coronary artery disease. If stress test and or cardiac enzymes are positive, a cardiac catheterization is warranted.  Right carotid bruit was auscultated indicating need for doppler studies. Patient may need referral to vascular surgeon for carotid disease evaluation. If his symptoms worsen, he needs to seek medical help immediately.  Medications             Brian’s blood pressure is elevated despite Lopressor. Additional medication is needed to maintain a normal blood pressure. Cardizem is a good second medication to add to Lopressor since he is over fifty-five. If a blood pressure cannot be maintained, an ACE would likely be added to the regimen. He will also need sublingual nitro to use for intermittent chest pain not relieved by rest.  Education             Any new medications prescribed have potential side effects. Brian needs to be aware of the possibility that sublingual nitro can quickly drop blood pressure and cause headache. Also, he will need to monitor his blood pressure daily with the addition of Cardizem. Hypotension can cause injuries if patient becomes syncopal and falls. If he experiences any side effect, he needs to know what he is supposed to do. Once work up is complete and a diagnosis is made, Brian will need to begin an exercise program. He will also need to address his diet so he is reducing his fat and cholesterol intake.  Ethical and Legal Standards Ethical codes are systematic guidelines for shaping ethical behavior that answer the normative questions of what beliefs and values should be morally accepted (Butts, J. B., 2017). The building blocks of professional ethics in patient care are, nonmaleficence, beneficence, autonomy, and confidentiality. Simply stated, do no harm, do good, patients have the right to decide what is best for them, and all information exchanged with the patient is confidential. As students, it can be a struggle between learning and doing no harm. The learning is never more important, however, without it harm maybe done. As society becomes more technologically savvy, virtual learning environments have afforded the opportunity to learn in a safe environment. This allows new practioners to go out into the real world with a more highly developed skill set than ever before.  Cultural Considerations Culturally congruent practice is the application of evidence-based nursing that is in agreement with the preferred cultural values, beliefs, worldview, and practices of the healthcare consumer and other stakeholders. Cultural competence represents the process by which nurses demonstrate culturally congruent practice. Nurses design and direct culturally congruent practice and services for diverse consumers to improve access, promote positive outcomes, and reduce disparities. (Marion, L., Douglas, M., Lavin, M. A., Barr, N., Gazaway, S., Thomas, E., & Bickford, C., 2017). As a student, it is important not to only focus on the clinical symptoms, but to remember the impact of the patients’ culture. This can influence every aspect from the treatment plan to it being implemented. Experts recommend letting patients establish their cultural identity by probing four key areas during the patient interview: the individual’s cultural identity; cultural explanations of the individual’s illness; cultural factors related to the psychosocial environment and levels of function; and cultural elements in the clinician- patient relationship (Bickley, L. S., 2013).    Conclusion            Heart disease is the leading cause of death in the United States (cdc.org., 2017). Brian Foster has had three episodes of exertional chest pain in the last month. Multiple risk factors put him at an increased risk for coronary artery disease. Once diagnostic exams and laboratory results are complete, a diagnosis can be made as to the cause of his chest pain. Differential diagnosis will be coronary artery disease with stable angina. Aortic stenosis cannot be ruled out. Cardiac catheterization is likely in this case if cardiac enzymes or stress test are positive. One study reported a case where diet and lifestyle modifications, along with lipid lowering therapy, led to the significant regression of coronary artery stenosis (Narayan, P., & Khetan, A., 2015). Once treatment has been successful in releiving Brian’s exertional chest pain, an exercise program, dietary changes, and continuation of lipid lowering medication may yield similar results for him.    Focus of Assessment : Brian Foster is a fifty - eight - year - old Caucasian male that has come in to be evaluated for three episodes of intermittent chest pain that has occurred over the last month. This is the first time he has sought out medical evaluation. The objective is to dis cern the cause of the intermittent chest pain by using sound clinical reasoning. Clinical reasoning can only be developed through experience. Each examination of patient brings about a new learning opportunity to further build clinical expertise. Subjectiv e Finding s Brian comes to the clinic complaining of three episodes of chest pain in the last month. Two episodes were related to increased activity. The first during heavy yard work and the second walking up four flights of stairs at work. Over eating at his wife’s birthday dinner precipitated the third episode three days ago. During each event, he reports the pain came on suddenly, was in the center of his chest but did not radiate. He describes the pain as a feeling of tightness and being unco mfortable. Pain was reported as five on a numerical pain scale of zero to ten, and lasted only for a few minutes. He denies shortness of breath, syncope, cough, numbness, tingling, nausea, diaphoresis, or heart burn during chest pain events. Resting minima lly helps to relieve the pain and thus far he has not taken any medication related to the chest pain. He feels the pain has not been severe enough to consider it an emergency, but does want to have his heart checked out. He currently denies having chest pa in and reports his pain as zero. Medical Histor y Brian reports he has a history of hypertension and hyperlipidemia. Prescription medications are Lopressor 100mg daily and Lipitor 20 mg daily at bedtime. For occasional body or headaches, he uses Tylenol or Advil and follows the direction on the bottle. 1200mg of Fish oil is the only supplement he currently takes. Brian reports an allergy to codeine that causes nausea but no other known allergies. He denies being treated for chest pain in the pas t, coronary artery disease, diabetes, or respiratory issues. Last year during his annual exam, a twelve - lead electrocardiogram was performed and reported as normal. Social Histor y Brian is married with one daughter and reports a low stress life at home and work. He does not exercise daily but expressed interest in riding a bike once he is feeling better. Breakfast consists of a granola bar or instant breakfast packet. Occasionally he has a large breakfast consisting of eggs, potatoes and bacon. Lunch is typ ically a turkey sub or salad. He often grills meat and vegetables for dinner. Brian drinks two cups of coffee each day and one liter of water. He reports no illicit drug use and does not smoke. On the weekends, he drinks two or three beers over the weekend . Review of system s In general, he denies fever, fatigue, weight loss, palpitations, syncope, or night sweats. No cardiovascular history of murmur, edema, or coagulopathy. Respiratory history negative for productive or nonproductive cough or shortness of b reath. No gastrointestinal history of heartburn, nausea, vomiting, GERD, constipation or diarrhea. No Musculoskeletal issues of back pain, arthritis, or recent injuries. Focus of Assessment: Brian Foster is a fifty-eight-year-old Caucasian male that has come in to be evaluated for three episodes of intermittent chest pain that has occurred over the last month. This is the first time he has sought out medical evaluation. The objective is to discern the cause of the intermittent chest pain by using sound clinical reasoning. Clinical reasoning can only be developed through experience. Each examination of patient brings about a new learning opportunity to further build clinical expertise. Subjective Findings Brian comes to the clinic complaining of three episodes of chest pain in the last month. Two episodes were related to increased activity. The first during heavy yard work and the second walking up four flights of stairs at work. Over eating at his wife’s birthday dinner precipitated the third episode three days ago. During each event, he reports the pain came on suddenly, was in the center of his chest but did not radiate. He describes the pain as a feeling of tightness and being uncomfortable. Pain was reported as five on a numerical pain scale of zero to ten, and lasted only for a few minutes. He denies shortness of breath, syncope, cough, numbness, tingling, nausea, diaphoresis, or heart burn during chest pain events. Resting minimally helps to relieve the pain and thus far he has not taken any medication related to the chest pain. He feels the pain has not been severe enough to consider it an emergency, but does want to have his heart checked out. He currently denies having chest pain and reports his pain as zero. Medical History Brian reports he has a history of hypertension and hyperlipidemia. Prescription medications are Lopressor 100mg daily and Lipitor 20 mg daily at bedtime. For occasional body or headaches, he uses Tylenol or Advil and follows the direction on the bottle. 1200mg of Fish oil is the only supplement he currently takes. Brian reports an allergy to codeine that causes nausea but no other known allergies. He denies being treated for chest pain in the past, coronary artery disease, diabetes, or respiratory issues. Last year during his annual exam, a twelve-lead electrocardiogram was performed and reported as normal. Social History Brian is married with one daughter and reports a low stress life at home and work. He does not exercise daily but expressed interest in riding a bike once he is feeling better. Breakfast consists of a granola bar or instant breakfast packet. Occasionally he has a large breakfast consisting of eggs, potatoes and bacon. Lunch is typically a turkey sub or salad. He often grills meat and vegetables for dinner. Brian drinks two cups of coffee each day and one liter of water. He reports no illicit drug use and does not smoke. On the weekends, he drinks two or three beers over the weekend. Review of systems In general, he denies fever, fatigue, weight loss, palpitations, syncope, or night sweats. No cardiovascular history of murmur, edema, or coagulopathy. Respiratory history negative for productive or nonproductive cough or shortness of breath. No gastrointestinal history of heartburn, nausea, vomiting, GERD, constipation or diarrhea. No Musculoskeletal issues of back pain, arthritis, or recent injuries. Hello. I will be interviewing you today, and later conduct a physical exam Greet 03/25/20 10:27 AM PDT Good morning. Please let me know your name (Clarified to Can you verify your identity please?.) Question 03/25/20 10:28 AM PDT Brian Robert Foster. (Clarified to to confirm what is my name.) Welcome Mr Foster. What brings you to the clinic today? Question 03/25/20 10:29 AM PDT I have been having some troubling chest pain in my chest now and then for the past month. I am sorry that you have been having the chest pain. brian foster chest pain shadow health assessment Transcript Empathize 03/25/20 10:30 AM PDT Thanks. I appreciate that. Please tell me what the pain you have been having is like (Clarified to Can you tell me what the pain is like?.) Question 03/25/20 10:31 AM PDT Well, it mostly feels tight and uncomfortable right in the middle of my chest. (Clarified to if I can tell you what the pain is like.) when did the pain start? Question 03/25/20 10:32 AM PDT I first noticed it earlier this month. I thought it might just be heartburn and it passed after about a couple of minutes. does the chest pain radiate? Question 03/25/20 10:33 AM PDT The pain doesn’t radiate anywhere. It’s mostly just right in the middle of my chest. Do you feel pain in your arm? Question 03/25/20 10:33 AM PDT No, when I am having the chest pain, it’s mostly just in middle of my chest. do you feel pain in your shoulder? Question 03/25/20 10:36 AM PDT No, the pain hasn’t been in my shoulder. do you have back pain? Question 03/25/20 10:36 AM PDT I haven’t had back pain, no. do you have neck pain. Question 03/25/20 10:37 AM PDT My neck’s been fine. how long does the chest pain last ? Question 03/25/20 10:37 AM PDT When I feel it, it seems to get better over the course of a couple of minutes or so. what is the frequency of the chest pain? Question 03/25/20 10:37 AM PDT Well, it has happened three times the past month. It usually goes away after about a couple of minutes. Were episodes of your chest pains related? (Clarified to What were you doing the last time you had chest pain?.) Question 03/25/20 10:39 AM PDT Well, the pain seems to start when I’m doing something physical . . . the first time it happened while I was doing yard work, and the second time . . . I had to take the stairs at work because the elevator broke. Both times it got better if I took a break or sat down to rest. (Clarified to what I was doing when I had chest pain last.) how do you feel when in pain? (No matching questions found.) Question 03/25/20 10:41 AM PDT am sorry about that? (No matching questions found.) Question 03/25/20 10:42 AM PDT How would you rate the chest pain? Question 03/25/20 10:43 AM PDT When I’m having it, it’s really tight and uncomfortable. Maybe like a 5 out of 10. Right now it’s like a zero. is the pain crushing ? Question 03/25/20 10:43 AM PDT No, it’s more tight and uncomfortable. Am sorry about that. (No matching questions found.) Question 03/25/20 10:44 AM PDT Am sorry about that. Empathize 03/25/20 10:44 AM PDT Thanks. I appreciate that. is the pain gnawing? Question 03/25/20 10:44 AM PDT No, it’s not like that. [AUDIO COMING SOON] is the pain burning ? Question 03/25/20 10:45 AM PDT Not really. is the pain aggravated by activity? Question 03/25/20 10:45 AM PDT Well, I think it’s when I’m doing something physical most of the time. The first time it happened, my chest started hurting after I was doing some yard work. The second time happened when the elevator broke at work so I had to take the stairs. My office is on the 5th floor. Thats understandable (No matching questions found.) Question 03/25/20 10:46 AM PDT Thats understandable Empathize 03/25/20 10:46 AM PDT Thanks. I appreciate that. does eating make your pain get worse ? (Clarified to Do certain foods make the pain worse?.) Question 03/25/20 10:47 AM PDT I don’t think that has anything to do with it, but I guess I don’t know. (Clarified to if certain foods make the pain worse.) does lying down help your pain? Question 03/25/20 10:48 AM PDT I’m not sure. I think lying still seems to help a little. Have you taken medication for the pain? Question 03/25/20 10:48 AM PDT No, not yet. Have you taken any anxiety medication? Question 03/25/20 10:49 AM PDT I’ve never taken anxiety meds. My life is pretty easy. [AUDIO COMING SOON] Have you taken any medication? Question 03/25/20 10:53 AM PDT Yeah, let’s see, I take atorvastatin for cholesterol, metoprolol for blood pressure. . . Oh yeah, and I take fish oil too. I hear that’s good for your cholesterol. [AUDIO COMING SOON] True, that good for your cholesterol, continue taking it. Educate 03/25/20 10:54 AM PDT Good to know. Thank you. What dosage of metoprolol do you take? Question 03/25/20 10:56 AM PDT I think it’s 100 mg, once a day. what about the dose of atorvastatin medication? (No matching questions found.) Question 03/25/20 10:57 AM PDT what is the dose of atorvastatin medication? Question 03/25/20 10:58 AM PDT I think it’s twenty milligrams a day. How long have you been taking atorvastatin and metoprolol? (No matching questions found.) Question 03/25/20 10:58 AM PDT How long have you been taking atorvastatin? Question 03/25/20 10:59 AM PDT I think about a year. [AUDIO COMING SOON] How long have you taken metoprolol? Question 03/25/20 10:59 AM PDT I think it’s been about one year. Are you allergic? Question 03/25/20 11:01 AM PDT No, well . . . I’ve had a bad reaction to codeine before, but that is all I know of. Have you been diagnosed with hypertension? Question 03/25/20 11:02 AM PDT Yes, I supposedly have moderately high blood pressure. Am sorry to hear this? Empathize 03/25/20 11:02 AM PDT Thanks. I appreciate that. have you been told your cholesterol is high? Question 03/25/20 11:03 AM PDT I’ve been told it’s moderately high. I’ve never noticed any actual symptoms from that though. Have you been tested for diabetes? Question 03/25/20 11:04 AM PDT My mom and my sister both have diabetes, but I don’t have it. Did you have any treatment for chest pain? Question 03/25/20 11:06 AM PDT I don’t have any shortness of breath, just the chest pain. Have you been monitoring your blood pressure? Question 03/25/20 11:07 AM PDT Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it. do you remember your last blood pressure readings? Question 03/25/20 11:08 AM PDT I don’t remember. I don’t think it was too bad, though. have you done an EKG test recently? Question 03/25/20 11:08 AM PDT I had one about three months ago. They usually put one on me at my annual physical. well, an EKG test is all about blood pressure monitoring. Educate 03/25/20 11:09 AM PDT Good to know. Thank you. what was the result of the EKG? Question 03/25/20 11:09 AM PDT I don’t remember the actual results, but as far as I know, it was normal. Do you have a primary care provider? Question 03/25/20 11:10 AM PDT Dr. Melinda Smith. Great. Educate 03/25/20 11:10 AM PDT Good to know. Thank you. When did you last visit your care provider? Question 03/25/20 11:10 AM PDT I had a physical about 3 months ago. Do you have stress? Question 03/25/20 11:11 AM PDT Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest. Am sorry about this. Empathize 03/25/20 11:11 AM PDT Thanks. I appreciate that. Do you exercise? Question 03/25/20 11:12 AM PDT Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having. Am sorry that the chest pain makes you not exercise. Empathize 03/25/20 11:13 AM PDT Thanks. I appreciate that. what is your typical breakfast? Question 03/25/20 11:13 AM PDT I usually have something. Most days I drink an instant breakfast, or I’ll have a granola bar. Sometimes Maria will make a big breakfast on weekends with eggs, pancakes, bacon, hash browns, that kind of stuff. what is your typical lunch? Question 03/25/20 11:14 AM PDT There’s a sub shop near the office, so I usually get a turkey or Italian sub from there. Sometimes a salad if I’m feeling healthy . . . or guilty. what is your typical dinner? Question 03/25/20 11:14 AM PDT My wife and I like to grill. We usually have some grilled meats and veggies for dinner. do you take salt? (No matching questions found.) Question 03/25/20 11:15 AM PDT Do you drink water regularly? Question 03/25/20 11:15 AM PDT I usually drink water all day at work. At least four glasses, probably more. [AUDIO COMING SOON] Its good to take water, continue. Educate 03/25/20 11:16 AM PDT Good to know. Thank you. Do you smoke cigarettes? Question 03/25/20 11:17 AM PDT Nope, I had a lot of friends who did but I never started. Do you take alcohol? Question 03/25/20 11:17 AM PDT I rarely drink during the week. If I drink at all it’s a couple beers on the weekend while I’m grilling or watching football. Maybe a little bourbon occasionally. thats moderate drinking. Educate 03/25/20 11:18 AM PDT Good to know. Thank you. Do you have fever? Question 03/25/20 11:18 AM PDT I haven’t had a fever, no. do you have chills? Question 03/25/20 11:18 AM PDT I haven’t had chills, no. Do you have fatigue? Question 03/25/20 11:18 AM PDT I’m not more tired than normal. do you have night sweats ? Question 03/25/20 11:19 AM PDT Nope, no night sweats. Do you feel dizzy? Question 03/25/20 11:19 AM PDT No, I haven’t felt dizzy. Do you have palpitations? Question 03/25/20 11:19 AM PDT I don’t think so. I haven’t noticed any. Have you had angina? Question 03/25/20 11:20 AM PDT I’ve never been diagnosed with angina. [AUDIO COMING SOON] have you ever had edema? Question 03/25/20 11:20 AM PDT I haven’t noticed any swelling. have you had blood clots? Question 03/25/20 11:20 AM PDT Not that I know of. Any history of of rheumatic fever? Question 03/25/20 11:21 AM PDT No, I never had that. do you have history of heart murmur? Question 03/25/20 11:21 AM PDT No, none that I know of. do you have a cough? Question 03/25/20 11:22 AM PDT I don’t have a cough. do you have difficulty breathing? Question 03/25/20 11:22 AM PDT My breathing’s fine. Do you have orthopnea? Question 03/25/20 11:22 AM PDT Orthopnea? That sounds like the name of a weird bird. [AUDIO COMING SOON] Well, Thats shortness of breath? Educate 03/25/20 11:23 AM PDT Good to know. Thank you. Do you have shortness of breath? Question 03/25/20 11:23 AM PDT My breathing’s fine. Do you have sore throat? Question 03/25/20 11:24 AM PDT I haven’t had a sore throat in a long time. Do you have change in sense of taste? Question 03/25/20 11:24 AM PDT I can still taste things fine. Do you have dysphagia? Question 03/25/20 11:25 AM PDT I haven’t had any trouble swallowing. Do you have nausea? Question 03/25/20 11:25 AM PDT No, I haven’t felt nauseous. I just had pain in my chest. do you have diarrhea ? Question 03/25/20 11:28 AM PDT I have, but it is very rare for me. Do you have constipation? Question 03/25/20 11:29 AM PDT I haven’t had problems with that. I wish it were only that. do you have heartburn or GERD? Question 03/25/20 11:29 AM PDT No, I’ve never had problems with heartburn. I sure hope that’s all this is, but it’s pretty intense if it’s heartburn. Do you have a family history of heart attack? brian foster chest pain shadow health assessment Transcript Question 03/25/20 11:30 AM PDT Well, my mom’s dad died of a heart attack. He was pretty young too. Do you have a family history of stroke? Question 03/25/20 11:30 AM PDT No, none that I know of. Do you have a family history of pulmonary embolism? Question 03/25/20 11:32 AM PDT No, nobody had that. Thank you Mr Foster for answering for answering my questions, I will now do the Physical examination. (No matching questions found.) Question 03/25/20 11:34 AM PDT Thank you Mr Foster for answering for answering my questions, I will now do the Physical examination. brian foster chest pain shadow health assessment Transcript Educate 03/25/20 11:34 AM PDT Good to know. Thank you.  Auscultated over spleen brian foster chest pain shadow health assessment Transcript Exam Action 03/25/20 1:19 PM PDT  Palpated right carotid pulse: Thrill, 3+ Exam Action 03/25/20 1:21 PM PDT  Palpated left carotid pulse: No thrill, 2+ Exam Action 03/25/20 1:21 PM PDT  Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm Exam Action 03/25/20 1:22 PM PDT  Palpated right brachial pulse: No thrill, 2+ Exam Action 03/25/20 1:23 PM PDT  Palpated left brachial pulse: No thrill, 2+ Exam Action 03/25/20 1:23 PM PDT  Palpated right radial pulse: No thrill, 2+ Exam Action 03/25/20 1:25 PM PDT  Palpated left radial pulse: No thrill, 2+ Exam Action 03/25/20 1:26 PM PDT  Palpated right femoral pulse: No thrill, 2+ Exam Action 03/25/20 1:26 PM PDT  Palpated left femoral pulse: No thrill, 2+ Exam Action 03/25/20 1:27 PM PDT  Palpated right popliteal pulse: No thrill, 1+ Exam Action 03/25/20 1:27 PM PDT  Palpated left popliteal pulse: No thrill, 1+ Exam Action 03/25/20 1:27 PM PDT  Palpated right tibial pulse: No thrill, 1+ brian foster chest pain shadow health assessment Transcript Exam Action 03/25/20 1:28 PM PDT  Palpated left tibial pulse: No thrill, 1+ Exam Action 03/25/20 1:28 PM PDT  Palpated right dorsalis pedis pulse: No thrill, 1+ Exam Action 03/25/20 1:30 PM PDT  Palpated left dorsalis pedis pulse: No thrill, 1+ Exam Action 03/25/20 1:30 PM PDT  Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 03/25/20 1:31 PM PDT  Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 03/25/20 1:31 PM PDT  Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 03/25/20 1:31 PM PDT  Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 03/25/20 1:31 PM PDT  Palpated right upper quadrant with deep pressure: No masses Exam Action 03/25/20 1:32 PM PDT  Palpated right lower quadrant: with deep pressure: No masses Exam Action 03/25/20 1:32 PM PDT  Palpated left lower quadrant with deep pressure: No masses Exam Action 03/25/20 1:32 PM PDT  Palpated left upper quadrant with deep pressure: No masses Exam Action 03/25/20 1:32 PM PDT  Palpated liver: Palpable 1 cm below right costal margin Exam Action 03/25/20 1:33 PM PDT  Palpated for spleen: Not palpable Exam Action 03/25/20 1:34 PM PDT  Palpated for right kidney: Not palpable Exam Action 03/25/20 1:34 PM PDT  Palpated for left kidney: Not palpable Exam Action 03/25/20 1:34 PM PDT  Tested skin turgor Exam Action 03/25/20 1:34 PM PDT  Percussed right upper quadrant Exam Action 03/25/20 1:36 PM PDT  Percussed right lower quadrant Exam Action 03/25/20 1:36 PM PDT  Percussed left upper quadrant Exam Action 03/25/20 1:36 PM PDT  Percussed left lower quadrant Exam Action 03/25/20 1:36 PM PDT  Percussed spleen Exam Action 03/25/20 1:37 PM PDT  Percussed for liver span: 7 cm in the mid-clavicular line Exam Action 03/25/20 1:38 PM PDT  Performed EKG Exam Action 03/25/20 1:38 PM PDT  Inspected left side of abdomen Exam Action 03/25/20 1:43 PM PDT  Inspected front of abdomen Exam Action 03/25/20 1:46 PM PDT  Inspected left side of abdomen brian foster chest pain shadow health assessment Transcript Exam Action 03/25/20 1:46 PM PDT Hello. I will be interviewing you today, and later conduct a physical exam Greet 03/25/20 10:27 AM PDT Good morning. Please let me know your name (Clarified to Can you verify your identity please?.) Question 03/25/20 10:28 AM PDT Brian Robert Foster. (Clarified to to confirm what is my name.) We lcome Mr Foster. What brings you to the clinic today? Question 03/25/20 10:29 AM PDT I have been having some troubling chest pain in my chest now and then for the past month. I am sorry that you have been having the chest pain. brian foster chest pain shadow health assessment Transcript Empathize 03/25/20 10:30 AM PDT Thanks. I appreciate that. Please tell me what the pain you have been having is like (Clarified to Can you tell me what the pain is like?.) Question 03/25/20 10:31 AM PDT Well, it mostly feels tight and uncomfortable right in the middle of Hello. I will be interviewing you today, and later conduct a physical exam Greet 03/25/20 10:27 AM PDT Good morning. Please let me know your name (Clarified to Can you verify your identity please?.) Question 03/25/20 10:28 AM PDT Brian Robert Foster. (Clarified to to confirm what is my name.) Welcome Mr Foster. What brings you to the clinic today? Question 03/25/20 10:29 AM PDT I have been having some troubling chest pain in my chest now and then for the past month. I am sorry that you have been having the chest pain. brian foster chest pain shadow health assessment Transcript Empathize 03/25/20 10:30 AM PDT Thanks. I appreciate that. Please tell me what the pain you have been having is like (Clarified to Can you tell me what the pain is like?.) Question 03/25/20 10:31 AM PDT Well, it mostly feels tight and uncomfortable right in the middle of