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

Student Documentation

Model Documentation

Subjective

Mr. Foster is 58 years old Caucasian male. Chief Complaint: Patient stated, "I have been having some troubling chest pain in my chest now and then for the past month". HPI: Mr. Foster reported that the onset on the chest pain was a month ago, and it lasted about few minutes. At first, he said, I first noticed it earlier this month, I thought it might just be heartburn and it passed after a couple of minutes". He said that he feels the pain mostly in the middle of his chest over his heart. He said that the chest pain happened three times in the past month. And she said it usually goes away after about a couple of minutes. He said that the does not radiate to any other part of his body. He said that the pain usually starts when He is doing something physical, especially when is doing yard work and the second time. Also, when he takes stair ways at work due to broken elevator. He rated the pain the pain 5 out of 0-10, The pain gets better when he is rested and lying down. His last chest pain was last week Friday evening when he was taking stairs at work. He stated that the pain feels very tight and uncomfortable. This is the first time he has seen a care provider about the pain. He said it would be crazy if he has the pain at work, and it would be distracting him a lot.

Confirmed Medications: Metoprolol 100 mg, 1 tab., PO, daily for hypertension in the morning. Atorvastatin 20 mg, PO daily, at 10 PM, for hyperlipidemia in the evening. Omega-3 fish oil 1200mg 1 cap, PO daily int morning. Tylenol or Motrin when having headache

Diagnostic Test: reported EKG done before and stress, and both were normal last all primary care doctors 3 month ago. He said that he sees his primary Care Provider (PCP) every 6 months.

Allergies: Codeine. When he takes codeine, he experiences nausea and vomiting.

PMHx: Hypertension-stage 2, diagnosed 1 year ago. Hyperlipidemia, diagnosed 1 year ago No surgical history.

Immunization: Tdap 10/2014

Influenza vaccine is up to date.

Family history:

Father- Hypertension, hyperlipidemia, obesity, and deceased at age 75 years of colon cancer

Mother- Type 2 diabetes, Hypertension, age 80 years old.

Brother- died of motor vehicle accident at 24 years.

Sister- Age 52, has Type 2 diabetes, Hypertension.

Maternal grandfather: Died at age 54 of heart attack.

Maternal grandmother: died of breast cancer at age 65 years.

Paternal grandmother: Died of pneumonia at age 78.

Paternal grandmother: Died at 85 of old age.

Son: 26 years old and healthy.

Daughter: Age 19, diagnosed of asthma.

ROS: General: Mr. Foster denied night sweat, fever, fatigue, and no recent illness. Skin: No rashes, no lesions, and no changes of the skin noted. No sore throat reported, no shortness of breath, and no difficulty swallowing. Reported no change on family history.

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Objective

V/S: T=36.7C (98.1F), HR=104, RR=19, B/P=146/90, Sa02=98%. Weight: 197 lbs. Height: 5'11"

Face inspected without no visible abnormal findings. JVD inspected and was measured 3cm above the sternal angle. Chest walls were symmetrical without visible abnormal findings. Abdomen inspected, flat and symmetrical in all quadrants without visible abnormal findings. Bilateral hands inspected; the appearance revealed no visible abnormal findings. Lower extremities inspected, including examining toenails, legs bilaterally for edema and there is edema noted. Capillary refills both finger nails and toe nails tested and was present less than 3 seconds and no visible abnormal findings noted. The right carotid artery auscultated and bruit was present, left artery auscultated and no bruit indicated. Heart sound auscultated and S1, S2, and S3 sounds were noted around the mitral valve. Breath sound auscultated and all sounds are present, adventitious sounds noted around the posterior right and left lower lobes, fine crackles heard. Abdominal aorta auscultated and no bruit noted. Abdominal and lower extremity arteries were auscultated and no bruit. Auscultated bowel sounds in all 4 quadrants are present. Liver and spleen auscultated without friction rub noted. Carotid arteries palpated with thrill and +3 noted on the right carotid, left palpated and no thrill, +2 noted. Palpated PMI is displaced laterally brisk and tapping and less than 3 cm. Palpated brachial arteries no thrill+2. Palpated left and right femoral pulse without thrill +2. No tenderness reported upon light palpation of all four abdominal quadrants, no masses, no abnormal findings noted. Palpable 1 cm on the location of the liver below the right coastal margin was noted. No palpable spleen, no palpable left and right kidneys upon palpation, Skin turgor warm and no tenting noted. All four quadrants of abdomen percussed and no areas of dullness noted. spleen percussed and no abnormality noted. Liver percussed and liver span 7 cm noted in the midclavicular line. EKG result showed regular sinus rhythm and no ST-elevation or any changes.

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Assessment

Diagnosis: Angina pectoris Bilateral basal crackle Elevated high blood pressure Hyperlipidemia Inactive lifestyle.

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Plan

Doppler study of the pulse, Stress test for exercise EKG, Order for nitroglycerin to manage symptoms, daily aspirin regimen, educate patient to reduce salt intake, educate patient to monitor the signs of worsening symptoms, educate patient to start exercise to help control hyperlipidemia, seek immediate medical attention if signs and symptoms worsen and follow up with your doctor.

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