I have provided the template which will guide you now to complete the Case study assessment and examples with all the information regarding the pediatric patient. It is rewriting the information provided. You can choose any diagnosis to complete the assignment.(Chest Pain Assessment Essay)
- 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?
Chest Pain Assessment Essay-Sample Solution
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA
Chief Complaint (CC): I have been experiencing chest pain in the recent weeks.
History of Present Illness (HPI): The patient has been experiencing recurring chest pain in the past weeks. Brian Foster is a r 58-year-old Caucasian male. He has PMH of HTN and HLD, and describes chest pain as uncomfortable, tight and burning. His Midsternal chest pain range is 6/10. However, he denies experiencing chest pain during interview. He has not taken any medication to treat chest pain. His chest pain lasts for few minutes. The pain is highly noticeable and worsens after movement. His last physical exam was one year ago. His main diet is comprised of grilled meat, some sandwiches, and vegetables. The patient does not use spicy foods. He does not feel weakness and nausea. His is not coughing or vomiting. Experiences anxiety because of his chest pain.(Chest Pain Assessment Essay)
Medications
Metoprolol (Lopressor) 100mg PO daily
Lisinopril (Prinivil) 20mg PO daily
Atorvastatin (Lipitor) 20 mg PO Daily at bedtime, last dose 10pm yesterday.
Omega-3 Fish Oil 1200 mg PO BID, last dose 8am (OTC supplement)
However, no medications for chest pain.(Chest Pain Assessment Essay)
Allergies
Denies any food allergy, latex, seasonal or environmental which may cause allergy.
Codeine which makes him feel nausea or vomiting.
Past Medical History (PMH)
Only HLD x 1 year with no other medical history(Chest Pain Assessment Essay)
Past Surgical History (PSH)
No past surgeries
Sexual/Reproductive History
Denies being involved in risky sexual activities
Personal/Social History
No history of smoking. He takes 2-3 bottles of beer with friends during weekends. Has used illicit drugs such as Cocaine, LSD, Shrooms during his college period. Denies using any of these drugs currently. Had been cycling as a physical exercise until his bike was stolen. Eats balanced diet. Married with 2 children.(Chest Pain Assessment Essay)
Immunization History
Tdap 10/2014 Influenza immunization.
Significant Family History
His father was obese, experienced hypertension, hyperlipidemia, and colon cancer which caused his death. Mother is 80-years-old with hypertension and Type II diabetes. Brother was killed at 24-years-old in a road accident. His sister has Type II diabetes, hypertension. Maternal grandfather died of heart attack while his paternal grandmother died of pneumonia. His son has no underlying condition, but daughter has asthma.(Chest Pain Assessment Essay)
OBJECTIVE DATA
Physical Exam
Vital signs: BP: 146/90Right Arm 146/88 Left Arm, Respiratory rate: 19, Pulse: 104, SPO2: 98% in room air, Height: 5’11, Weight: 197 lbs, Temperature: 36.7.
General: Has clear and coherent speech. Very alert and oriented. Well-groomed with good hygiene. Very cooperative and answers questions comprehensively.
Cardiovascular/Peripheral Vascular: Gallop present. No swelling or edema. Mitral region has S1, S2, S3. No presence of JVD. Has laterally displaced PMI. His LJP is present 3 cm above the sternal angle. Right side carotid with bruit while left carotid with has no bruit. Brachial radial femoral pulses without thrill 2+. Capillary less than 3 secs in all 4 extremities. Popliteal tibial, and dorsalis pedis pulses without thrill, 1+.(Chest Pain Assessment Essay)
Respiratory: clear breath sound to auscultation in upper lobes and RML. Has unlabored breathing, symmetrical chest rises and falls. Presence of fine crackles at the posterior lower lobes of both the left and right lungs.
Gastrointestinal: Round, soft and non-tender abdomen with normative bowel sounds in all four quadrants, Liver is 7 cm at the MCL and 1 cm below the right costal margin. Has no abdominal bruits. There is no tenderness or guarding to light or deep palpation. Bilateral kidney and spleen are not palpable. Has no masses palpated.(Chest Pain Assessment Essay)
Musculoskeletal: Full ROM in all extremities
Neurological: Follows commands, very alert and oriented.
Skin: Dry, warm, intact, with no scars, bruises, or rash.
Diagnostic Test/Labs: EKG sinus rhythm no ST elevation. To rule out MI, labs for cardiac enzymes was recommended. Echocardiogram was recommended to assess heart functions. Chest Xray displays enlarged heart or congestion, Coronary CT scan.
ASSESSMENT
Priority Diagnosis: Coronary artery disease
Coronary artery disease is the most important diagnosis for Brian Foster based on his symptoms. According to Ralapanawa and Sivakanesan (2021), chest pain is often experienced following the narrowing of coronary artery by a fatty plaque hence depriving the oxygenated blood to a part of the myocardium.(Chest Pain Assessment Essay)
Differential Diagnosis
Stable angina pectoralis
Stable angina pectoralis is characterized by the reoccurrence of predictable chest pains as a result of progressive narrowing of the coronary arteries, and thickening of the arterial lining (Erkinovna et al., 2022). Arteries which are constricted often lack elasticity to dilate, forcing them to supply oxygen to the myocardium during an increase in demand, leading to the occurrence of chest pain (Erkinovna et al., 2022). However, stable angina pectoralis was not appropriate diagnosis for Brian Foster as he did not report any symptom of fatigue which is highly evidenced among patients with this health condition.(Chest Pain Assessment Essay)
Myocardial Infarction (non-ST elevation)
The second differential diagnosis is Myocardial Infarction. According to Jenča et al. (2021), the Myocardial Infarction is caused by occlusion of progressive plaque at the coronary arteries which leads to prolonged ischemia. This condition leads to irreversible damage to the heart muscle.(Chest Pain Assessment Essay)
Carotid Artery Disease
The third differential diagnosis for Brian is Carotid Artery Disease. Carotid bruits are important indicators for underlying carotid artery disease (Katsiki & Mikhailidis, 2020). Specifically, Carotid Artery Disease is caused by cholesterol build-up in the blood vessels (Katsiki & Mikhailidis, 2020). In the case of Brian, BP elevated, hx hyperlipidemia, R carotid bruit were reported hence indicating potential of Carotid Artery Disease.(Chest Pain Assessment Essay)
References
Erkinovna, K. Z., Alisherovna, K. M., Davranovna, M. K., & Nizamitdinovich, K. S. (2022). Correction of Cytokine Imbalance in the Treatment of Stable Angina Pectoris. The Peerian Journal, 11, 64-70.
Jenča, D., Melenovský, V., Stehlik, J., Staněk, V., Kettner, J., Kautzner, J., … & Wohlfahrt, P. (2021). Heart failure after myocardial infarction: incidence and predictors. ESC heart failure, 8(1), 222-237.
Katsiki, N., & Mikhailidis, D. P. (2020). Diabetes and carotid artery disease: a narrative review. Annals of Translational Medicine, 8(19), 1-9.
Ralapanawa, U., & Sivakanesan, R. (2021). Epidemiology and the magnitude of coronary artery disease and acute coronary syndrome: a narrative review. Journal of epidemiology and global health, 11(2), 169-174.
