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BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE
Patient Name (Initials only): B.R DOB: March/10/1965 Gender:
Male Date examined: May 28, 2023
| CHIEF COMPLAINT “My chest pains” | ||||||
| HISTORY OF PRESENT ILLNESS | ||||||
| Mr. B.R., a 58-year-old man, complained of chest pain in the middle of his chest when he arrived at the emergency room. It starts abruptly and does not radiate. Moving up the stairs and exertion exacerbate the tight, painful discomfort. Resting reduces the pain. The patient continues with everyday activities despite the pain, which is not severe. Mr. B.R. experiences periodic and intermittent chest pain. In one month, he has experienced three pain bouts. Three days ago was the most recent incident. According to the patient, the pain is related to leg cramps. He does not, however, admit to having heartburn, orthopnea, syncope, indigestion, nausea, vomiting, exhaustion, or shortness of breath.(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| PAST MEDICAL HISTORY | ||||||
| B.R. denies previous medical conditions. | ||||||
| The patient denies previous hospitalization, surgery, or trauma. | ||||||
| Medications None | ||||||
| Allergies/Adverse Reactions None | ||||||
| Immunizations: Flu – 2019 Pneumonia – 2009 Tdap – Denied Zoster – Denied Covid – 2021, June | ||||||
| FAMILY HISTORY | ||||||
| The patient is the youngest of three siblings in a family of five. The father suffered from hypertension and coronary heart disease and died at 60. The mother had developed diabetes mellitus and high blood pressure and died at 68. His siblings are all still alive and well.(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| SOCIAL HISTORY The patient has a wife and kids. He is a call center manager and likes reading books and watching television. He does not smoke and occasionally drinks alcohol. Grilled meat, sandwiches, and vegetables are staples in his diet. Typically, he consumes grilled meat 4-5 times a week. On busy days, he eats fast food for lunch. Every day, he drinks 1-2 cups of coffee.(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| REVIEW OF SYSTEMS | ||||||
| Constitutional | ||||||
| Patient denies fatigue, dizziness, weakness, fever, and weight loss. | ||||||
| Eyes | ||||||
| B.R. denies visual impairment or blurry vision | ||||||
| Ears/Nose/Throat | ||||||
| Ears: denies hearing changes or ear pain. Nose: denies sneezing or change in the sense of smell, sinus pain, or pressure. Throat: denies difficulty swallowing- dry mouth – swollen lymph nodes(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| Mouth / Dental | ||||||
| Denies tooth decay and gum disease; the last visit to the dentist was one year ago. B.R. denies speech problems, sinus drainage, taste, snoring(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| Breast | ||||||
| N/A | ||||||
| Cardiovascular The patient reports chest pain at the mid-sternum of the chest, causing discomfort. | ||||||
| Respiratory Denies cough or chest tightness, difficulty breathing except during asthma attacks, and dyspnea on exertion. | ||||||
| Gastrointestinal(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| Denies nausea or vomiting, abdominal pain, no changes in bowel or bladder pattern, or constipation; denies diarrhea. | ||||||
| Genito-Urinary | ||||||
| Denies change in urinary pattern; denies dysuria or incontinence. He is heterosexual. B.R. denies a history of STDs and reports being sexually active with his wife, who is under birth control. | ||||||
| Male Reproductive | ||||||
| Denies any erectile or urinary problems | ||||||
| Female Reproductive N/A | ||||||
| Musculoskeletal Denies arthralgia and myalgia, arthritis gout or limitations in his range of motion, and trauma or fractures. | ||||||
| Neurological | ||||||
| The patient denies syncopal episodes or dizziness, paresthesia, change in memory or thinking pattern, disturbances or problems with coordination, and seizure history. | ||||||
| Skin | ||||||
| Denies rashes, itching, or bruising. Denies changes in skin color. | ||||||
| Endocrine | ||||||
| B.R. denies polyurea, polyphagia, polydipsia, or fatigue. He denies heat or cold intolerance or shedding of hair. | ||||||
| Hematologic/Lymphatic: | ||||||
| B.R. denies bruising, bleeding, and anemia. He has no history of blood transfusion or thrombolytic disorders. | ||||||
| Psychiatric | ||||||
| He denies a history of anxiety or depression, apart from when his father and mother died from an illness. He denies fatigue, sleep disturbances, delusions, or mental health history. B.R. denies suicidal and homicidal history or ideation.(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| PHYSICAL EXAMINATION (Please describe your findings from inspection, palpation, percussion, & auscultation and use the term “deferred” if you did not examine that area.) | ||||||
| Vital signs | Ht: 5’8 | Wt 198 | BMI 30.1 | |||
| Temp: 98.2F | Pulse 85 | BP 110/68 | ||||
| R.R. 18 | Pain 4/10 | |||||
| General Appearance | ||||||
| The patient appears healthy, dressed appropriately for the season, clean and well-groomed, with well-kempt hair. BMI indicates obesity.(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| Head Normocephalic and atraumatic. Patient denies headaches | ||||||
| Eyes Sclera anicteric, No conjunctival erythema, PERRLA | ||||||
| Ears/Nose/Throat | ||||||
| Oropharynx red, moist mucous membranes | ||||||
| Mouth / Dental | ||||||
| Teeth appear healthy and aligned. No odor or teeth decay. | ||||||
| Neck Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules. | ||||||
| Respiratory No wheezes and respirations are easy and regular. | ||||||
| Cardiovascular | ||||||
| Although the patient’s heartbeat and rhythm are regular, murmurs and other sounds are coming from her chest. The patient’s heart rate is constant, and capillaries refill in two seconds. S3 rub is noted at the mitral area. The JVP is 3cm above the sternal angle. A bruit was noted on the right carotid, which had a 3+ thrill.(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| Gastrointestinal No nausea or vomiting, no abdominal pain or bowel changes | ||||||
| Genitourinary/Gynecological No changes in urinary pattern, no dysuria or inconsistency, no STD, reports being sexually active with wife. | ||||||
| Lymphatic No axillary lymphadenopathy or swelling on palpation(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| Skin No rashes or bruising | ||||||
| Back, Extremities, Musculoskeletal | ||||||
| No arthralgia and myalgia, no arthritis gout or limitations in range of motion, no trauma or fractures | ||||||
| Neurological No syncopal episodes or dizziness, no paresthesia, no change in memory or thinking pattern, denies disturbances or problems with coordination.(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| Psychiatric No anxiety or depressive report, fatigue, sleep disturbances, or suicidal or homicidal ideation. | ||||||
| Previous Diagnostic Testing/Lab Results No previous diagnosis or lab tests | ||||||
| List 3 Differential Diagnoses with Rationale (pertinent positive and negative) | ||||||
| Coronary artery disease with stable angina | ||||||
| Congestive heart failure | ||||||
| Costochondritis Rationale The chest pain that characterizes B.R.’s typical angina is typically brought on by a buildup of plaque in the arteries that supply the heart with blood. B.R. is at risk for coronary artery disease due to his history of hypertension, hyperlipidemia, and familial myocardial infarction. He described the pressure in his mid-sternum as his chest pain. Angina can happen while the heart is working harder or at rest, and it can continue for five to thirty minutes. Usually eased with nitrate and rest. Right-sided carotid bruit and thrill are B.R.’s first signs of heart failure. Typically, more fluid causes an S3 gallop. Additionally, the bilateral posterior bases of his lungs displayed fine crackles. These signs and symptoms all point to Class II heart failure ( Inamdar & Inamdar, 2019). Physical activity is slightly restricted in patients with class II heart failure, who are comfortable at rest but experience heart failure symptoms during routine physical exercise( Shahjehan & Bhutta, 2022). When the patient started pulling weeds, the first thing that came to mind was a musculoskeletal condition like costochondritis. When doing repetitive upper body movements, the strain on the upper chest costal cartilage can feel like angina in the upper to mid-sternum region.(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| ASSESSMENT ICD-10 code I25 Coronary artery disease with stable angina (Confirmed Diagnosis) A mismatch in supply and demand is what causes stable angina. Symptoms frequently appear when the myocardial oxygen demand momentarily surpasses the myocardial oxygen supply. Stable angina is caused by several factors, with coronary artery stenosis being the most common cause (Gillen & Goyal, 2021). (BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE)An imbalance between the myocardial oxygen supply and the myocardial oxygen demand typically causes angina to emerge. Myocardial ischemia is most frequently caused by coronary artery stenosis. The stenosis prevents a sufficient delivery of cardiac oxygen during periods of high myocardial oxygen demand. The primary parameters affecting oxygen demand are heart rate, systolic blood pressure, myocardial wall tension, and myocardial contractility (Gillen & Goyal, 2021). The chest pain that characterizes B.R.’s typical angina is typically brought on by a buildup of plaque in the arteries that supply the heart with blood ( Schumann, Sood, & Parente, 2023). Angina can happen while the heart is working harder or at rest, and it can continue for five to thirty minutes. Usually eased with nitrate and rest.(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| PLAN Diagnostics: The patient needs a chest radiograph for pericardial effusion, pulmonary edema, and cardiomegaly. Also, an electrocardiogram would help examine the heart’s contraction, and the heart ECHO would help examine how the heart muscles are built. The thyroid function test refutes hypothyroidism and hyperthyroidism. A full blood count eliminates anemia. The erythrocyte sedimentation rate rules out inflammatory and chronic disorders. Differentiating between cardiac and non-cardiac causes of dyspnea uses B-type natriuretic peptide. Medications: Aspirin, 75 mg daily to 325 mg on alternate days, for primary prevention of myocardial infarctionHMG-CoA reductase inhibitors – simvastatin, 40 mg/day, to reduce myocardial infarctionACE inhibitors – Vasotec, 3.75 mg P.O. once daily, for blood pressure control (Gillen & Goyal, 2021). Non-Pharmacological Treatment: Physical therapy is typically the mainstay of treatment because symptoms can continue for days to months. Lifestyle Modifications Cholesterol reduction (Gillen & Goyal, 2021).Blood pressure controlWeight lossAerobic exercises Referral/Consults: The patient should see a cardiologist’s heart evaluation, medication adherence, and hypertension monitoring. Education: Educate the patient on medication adherence and potential side effects.Advise the patient to take rest and avoid strenuous activities. Follow Up: Return to the hospital after a week to check progress.(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) | ||||||
| REFERENCE (include at least one evidence-based guideline/peer-reviewed journal article to support the diagnosis and plan) Gillen, C., & Goyal, A. (2021). Stable Angina. In StatPearls [Internet]. StatPearls Publishing. Inamdar, A. A., & Inamdar, A. C. (2019). Heart Failure: Diagnosis, Management and Utilization. Journal of clinical medicine, 5(7), 62. (BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE)https://doi.org/10.3390/jcm5070062 Schumann, J. A., Sood, T., & Parente J. J. (2023). Costochondritis. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532931/ Shahjehan, R. D., & Bhutta, B. S. (2022). Coronary artery disease. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564304/(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) https://www.ncbi.nlm.nih.gov/ REFERENCE (include at least one evidence-based guideline/peer-reviewed journal article to support the diagnosis and plan) Gillen, C., & Goyal, A. (2021). Stable Angina. In StatPearls [Internet]. StatPearls Publishing. Inamdar, A. A., & Inamdar, A. C. (2019). Heart Failure: Diagnosis, Management and Utilization. Journal of clinical medicine, 5(7), 62. (BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE)https://doi.org/10.3390/jcm5070062 Schumann, J. A., Sood, T., & Parente J. J. (2023). Costochondritis. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532931/ Shahjehan, R. D., & Bhutta, B. S. (2022). Coronary artery disease. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564304/(BRIAN FOSTER DOCUMENTATION OF HISTORY AND PHYSICAL EXAM COMPREHENSIVE NURSING ESSAY EXAMPLE) https://www.ncbi.nlm.nih.gov/ | ||||||
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