Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

Student Documentation

Model Documentation

Subjective

Patient information; Brian Foster, 58-year-old Caucasian male.

CC; Mr. Foster stated, “I been having some troubling chest pain in my chest now and then for the past month”.

HPI; VS: B/P (L) arm 146/88 mm/hg (R) arm 146/90 MAP 109mmhg HR 104 BPM RR-19 02 Sat 98% RA Temp; 36.7 c (98 F) Onset of chest pain one month ago, lasting "few min" pt. states, "thought it may be heart burn". Reports tight and uncomfortable right in the middle of the chest. Denies any pain radiating, denies any arm pain, shoulder pain, neck pain or back pain. pain only lasts a few minutes. An uncomfortable feeling that lasts a few minutes reporting 3 episodes in the past month and all feels the same. pain currently a zero, when having chest pain is 5 out of 10 on pain scale. Patient describes pain as tight and uncomfortable. Patient denies crushing or burning pain to the chest. Laying down seems to alleviate the pain with a brief rest. Not taking any medications for chest pain. Episodes of chest pain started with physical activity while doing yard work. In the second episode was taking stairs at work. Denies any pain with food. Patient confirms all medications are still current and unchanged. No new allergies noted. Confirms hypertension diagnosis and hyperlipidemia diagnosis. Denies any angina coronary artery disease or previous chest pain treatments. Patient does not check blood pressure on a regular basis. only windows to the doctor states doctor does not seem concerned about the blood pressure. Current medications; metoprolol 100mg one po q day, atorvastatin 20mg po q day, last dose 10pm yesterday (hyperlipidemia), omega-3 fish oil 1200mg one po q day last dose, Thursday 8am over the counter. Denies any aspirin use but takes Tylenol or Motrin when having a headache, denies headache has been often. Report heavy EKG before a stress both normal lasts all primary care doctors 3 months ago. See's PCP every 6 months. Allergies: codeine (n/v). PHMx: hypertension stage 2 diagnosed 1 year ago, hyperlipidemia diagnosed 1 year ago, Denies any surgeries. influenza Up to date, TDAP 10/2014. Soc Hx; denies any illicit drug use or tobacco use. Patient does report drinks 2 to 3 alcoholic beverages per week. No unusual stress noted. no regular exercise, last regular exercise was 2 years ago. Diet consist of granola bars, turkey subs and grilled meat and vegies. unsure of salt intake. Reports drinking one liter of water a day. Drinks coffee 1 to 2 a day, denies illegal drugs and confirms alcohol intake. Fam Hx; Father- Hypertension, hyperlipidemia, obesity, deceased at age 75 of colon cancer. Mother- type 2 diabetes and hypertension 80 Brother- Deceased at age 25 MVA Sister- type 2 diabetes and hypertension age 52 Maternal grandfather- deceased at age 54 of a heart attack. Maternal grandmother- died of breast cancer at age 65. Paternal grandmother- died of pneumonia at age 78. Paternal grandfather- deceased at 85 years old, "old age" Son- healthy age 26 Daughter asthma age 19. ROS- General; denies any fatigue, increased sweating, fever or recent illness. No skin rashes or lesions or skin changes. No reports of sore throat or difficulty swallowing, no shortness of breath, ROS WNL. Confirmed family history. no changes.

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Objective

Exam: VS - left arm 146/88 mmhg right arm 146/90 mmhg MAP - 109 mmhg HR 104 BPM RR - 19 o2 sat - 98% RA Temp- 36.7C (98 F) Inspected face no visible abnormal findings. Inspecting jvd 3 com above the sternal angle. chest was inspected with symmetrical all the way around and no visible abnormal findings. Inspected abdomen and is symmetric and flat no abnormal findings visible. Inspected hands bilaterally appearance no visible abnormal findings and no nail changes noted. Inspected lower extremities and toenails bilateral no visible abnormal findings to the lower extremities and examine toenails bilaterally no visible abnormal findings noted inspected legs bilaterally for edema no edema noted. Capillary refill tested in all 10 fingers and all ten toes refill time Less than 3 seconds. Right carotid artery auscultated Bruit present. no bruit to left auscultation of carotid artery Auscultated heart sounds noted as 1 2 and 3 especially in the mitral valve area Auscultated breath sounds all sounds present noted adventitious sounds to the lower posterior right and left noting fine crackles and rales. Auscultating abdominal aorta, no bruit found. Upon examination of all abdominal arteries no bruit found. Upon auscultation of bowel sounds in all four quadrants present. Upon auscultation of liver and spleen no friction rubs noted. When palpating the right carotid artery noted thrill +3, left carotid palpation no thrill +2. Palpated PMI: displaced laterally brisk and tapping and less than 3 cm. Palpated bilateral brachial arteries no thrill 2+. Palpation of the left and right radial pulse no thrill, 2+. Palpated left and right femoral pulse no thrill +2. Upon palpation of bilateral tibial, dorsalis pedis pulse and popliteal pulse no thrill, 1+ diminished unilateral. Upon light palpitation of all four abdominal quadrants like pressure no tenderness reported no masses guarding or distention. Upon deep palpation of all four abdominal quadrants no masses or abnormal findings noted. Location of the liver a palpable 1 cm below the right costal margin noted. Palpated spleen not palpable. Palpated right and left kidneys not palpable. Skin turgor warm dry no tenting noted. Because all four quadrants of the abdomen no area of dullness noted. On percussion of the spleen no abnormalities noted. Upon percussion of liver span 7 cm in the midclavicular line. EKG performed regular sinus rhythm noted no ST-elevation or changes.

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Assessment

Diagnosis 1) Angina pectoris 2) Bilateral basal crackles 3) Elevated blood pressure 4) Hyperlipidemia 5) Inactive lifestyle

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Plan

Plan: 1) Doppler testing of pulse 2) Exercise EKG stress test 3) Refer to Cardiology for echocardiography in CT angiography. 4) Prescribed nitroglycerin for symptom management 5) Prescribed aspirin regimen 6) Educate patient on signs of worsening symptoms such as MI, CVA or unstable angina. 7) Educate on the importance of a healthy diet and exercise to help control hyperlipidemia 8) Educate on salt intake reduction due to hypertension 9) instruct patient to seek immediate medical attention if signs or symptoms worsen and follow up as needed.

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