Assignment

Clinical Documentation Template

Student: Deepak Sharma Site: Elgin Medical Ctr

Client’s Initials: MS Age : 64 Gender : Male Date: 04/07/2019

Subjective

Chief Complaint: 64 year old Hispanic male present to the clinic with chest discomfort.

HPI: Mr. JG. is a 64-year old male with a history of HTN and dyslipidemia present to the clinic with chest discomfort for past two month. Patient stated that chest discomfort is in the middle of his chest and it feels like a burning sensation along with tingling. Patient rated his pain 5 out of 10. Patient also stated that mostly happen when I am doing activity like climbing stairs however sometime it does happen when I am just watching TV. Patient denies any episodes of felling dizzy or passing out. Patient denied radiation of the pain to neck or jaw. He took Advil and it is not doing anything. Patient is non-compliance with his cholesterol medication.

ROS: General: has slowly gain weight over last ten years, denies weakness, , fevers, memory changes, nervousness, anxiety,depression, suicide.

Skin: no rash, lumps, sores, itching, dryness, color change, change in hair/nails, bruising or bleeding, excessive sweating, heat or cold intolerance.

Head: Denies headache, head injury, dizziness.

Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred

vision, or blindness.

Ears: no hearing change, tinnitus, infection, discharge.

Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.

Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.

Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.

Neuro: No syncope, seizures, weakness, paralysis, numbness, tremors, or involuntary

movements.

Pulmonary: Dyspnea with activity, negative hemoptysis, wheezing, pleuritic pain

Neuro: No headache dizziness, focal numbness/weakness, nausea, vomiting.

Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots,

abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness,

pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather.

Swelling with redness or tenderness.

MS: no muscle, joint pain, or joint stiffness, positive for chest pain

GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,

belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food

intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.

GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,

nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.

Past Medical History: Hypertension, dyslipidemia

Surgeries: none

Hospitalizations: None

Allergies: NKA

Food, drug, environmental: NKA

Medications: Lisinopril 5 mg daily

Hydrochlorothiazide 25 mg daily

Family History: His mother died at 72 and his father died at 88, both due to complications from HTN and CHF. He denies any known family history of autoimmune.

Social History: Drinks alcohol socially and has never used illicit substances. He categorizes his diet as good with a variety of foods (lean mean, fruit, vegetables, grains) but admits to eating mostly meat (chicken and red meat) with very few vegetable and grains up until about 2 years ago. He does not exercise on regular basis.

Objective

Vital Signs: BP: 136/80 Pulse: 86 RR : 16 Pain : 8/10 Height: 5’ 6” Weight : 220 lbs BMI: 35.5 SpO2: 98% RA

Labs: None

General Survey: 64 year old male sitting up in a chair in no apparent distress. Patient is cooperative, alert and oriented x 4. Speech is fluid and appropriate. Skin is warm and moist with adequate skin turgor and full hair distribution on scalp, trunk and extremities. No pallor, jaundice, cyanosis or clubbing. Capillary refill < 2 seconds on nails of hands and feet.

Exam : Head: hair normal texture and distribution, no lumps/bumps/lesions noted to scalp. Scalp/skull non-tender with palpation. Skull normocephalic/atraumatic. Eyes: no drainage noted, PERRLA, Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat. . Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddned bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline. Throat: oral mucosa pink and moist, tongue mobile without lesions, tonsils absent. Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid palpated. Trachea midline. Neuro: denies any numbness, .Alert and oriented x 4, CN I – not tested, II-XII intact. Deep tendon reflexes 2+ Brachioradialis, bicep, triceps, supinator, knee, and ankle with plantar reflexes down-going. No clonus. Muscle strength 5/5. Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs resonant. Breath sounds vesicular: no crackles or wheezes. No egophony or whispered pectoriloquy. Diaphragm descends 4cm bilat. Cardio: JVP is 3cm. above the sternal angle with the head of bed elevated to 30 degrees. Carotid upstrokes are brisk without bruits. Temporal arteries have normal pulsation without tenderness. The point of maximal impulse is taping, 8 cm lateral to the mid-sternal line in the 5th intercostal space. Crisp S1 S2 without clicks or murmurs. Extremities are warm and without edema. No variscosities or stasis changes. Calves are supple and non-tender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ and symmetric. Ca refill <2 secs. Abdomen: soft flat, non-tender and non-distended. Normoactive bowel sounds. No palpable masses or hepatosplenomegaly. Liver span is 7cm in the right midclavicular line. Edge not palpable. Kidneys not felt. No CVA tenderness. MS: Knee: Full active range of motion in all joints of the upper and lower ext. No evidence of swelling or deformity. Male Genitalia: deferred

Assessment Patient reports chest discomfort and shortness of breath with exertion and has history of hypertension and high cholesterol. The most likely diagnoses are as follows:

Differentials (with rationale for each): 1. Stable Angina: Evidence by chest discomfort and Shortness of breath on exertion.

2. Pulmonary embolism: Dyspnea is the most common symptom of acute pulmonary embolus

3. GERD: Esophageal reflux typically presents as an epigastric or retrosternal burning pain, with radiation toward the throat.

Diagnosis: Stable Angina

Plan

Diagnostics: 1. Resting EKG: May reveal ST-T changes suggestive of ischemia or Q waves indicative of prior infarction.

2. Stress Test

3. Coronary Angiogram

Treatment: The treatment goals of patients with Stable Angina are to:

· Reduce premature cardiovascular death

· Prevent complications of Angina (i.e., nonfatal myocardial infarction [MI] and heart failure) that lead to impaired functional status

· Maintain or restore level of activity and quality of life

· Completely, or nearly completely, eliminate anginal symptoms

Tx line	Treatment
Ist	Life style modification- Patient education includes ongoing assessments and recommendations to help patients achieve weight management, increased physical activity, dietary modifications, lipid goals.
Plus	Anti-platelet Therapy- All patients should be started on aspirin and this should be continued indefinitely. For patients with a contraindication to aspirin therapy, it is reasonable to use clopidogrel Asprin 75 mg to 162 mg daily OR Clopidrogel 75 mg daily
Adjunct	Antianginal Therapy- Carvedilol 6.25 to 25 mg orally twice daily
Adjunct	Atorvastatin - moderate intensity: 10-20 mg orally once daily; high intensity: 40-80 mg orally once daily For Acute Anginal Symptoms : nitroglycerine 0.4 mg sublinguial.
	Coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) is recommended to relieve anginal symptoms in patients with continued unacceptable angina despite maximal medical therapy

Follow up: With Cardiologist in one week.