Focused Note For Chest Pain Assignment Paper
Focused Note For Chest Pain Assignment Paper
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
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Subjective data
Chief Complaint: chest pain.
History of Presenting Illness: Mrs.G.M, 56 year old African American woman presented with complains of chest pain about four episodes in the last month. She describes the pain as being tight, on and off lasting for a few minutes, non-radiating, aggravated on exertion, not relieved by analgesics but relieved on rest with the most recent encounter being five days ago. Denies any history of acid reflux or trauma prior to the onset of symptoms Focused Note For Chest Pain Assignment Paper.
Medications
Enalapril 5mg OD.
Losartan H 1tab OD.
OTC tramadol 100mg BD.
Allergies
No known food, drug allergy.
Past medical History
Past Surgical History
Had an appendectomy 5 years ago.
Sexual/ Reproductive History
She identifies as heterosexual and has been married to her spouse for 20 years. She had two other sexual partners prior to that. She reports no changes in libido. She prefers vagina and oral sex. No history of sexually transmitted diseases. She is currently on IUCD method of contraception.
She para 3+0, all were via SVD. Last delivery was in 2018.
Personal/ Social History
She is married with three living children. She has no history of smoking cigarettes or illicit substance abuse. She has a positive history of alcohol consumption during social events.
Immunization History
The immunization schedule is up to date.
Significant Family History
She is the 5th born in a family of 6. All siblings are alive and well. Mother is alive and hypertensive. The father is deceased secondary to heart attack. Focused Note For Chest Pain Assignment Paper
Review systems
General: denies chills, fever or weight loss.
Cardiovascular/ Peripheral Vascular
Respiratory: denies difficulty in breathing, cough and shortness of breath.
Gastrointestinal: no history of abdominal pain, nausea, vomiting, constipation and diarrhoea.
Musculoskeletal: denies joint pain, stiffness or swelling.
Psychiatric: patient denies visual or auditory hallucinations. No history of depression or anxiety.
Objective Data
Vital signs: BP 128/78mm/hg, PR 68b/min, RBS 5.2mmol/L, SPO2 98% Room air, BMI 28.3KG/M2, RR 18 breaths/min
General: Mrs. G.M, 56 years old African American woman, is seated comfortably in a fair general condition.
Cardiovascular: the precordium is normoactive. S1 and S2 heard with no murmurs. There are no murmurs or rubs. S3 is noted over the mitral area with the PMI felt at this area. Has mild pitting pedal oedema to the level of the knee.
Respiratory: there are no obvious signs of respiratory distress. The chest is clear and there is equal and bilateral air entry.
Gastrointestinal: the abdomen is soft and moving with respiration.no tenderness or organomegally elicited. Bowel sounds are present.
Musculoskeletal: moves all extremities and there is no joint pain or stiffness.
Neurological: she alert, oriented in time, place and person. All cranial nerves are bilaterally and grossly intact.
Skin: pink, warm, intact and dry. No sweating or tenting.
Diagnostic tests
BNP: to assess the cardiac function and in diagnosing heart failure.
Cardiac enzymes: these are biomarkers of heart muscle damage.
Lipid profile: evaluate the various types of fat to rule out hyperlipidaemia.
CMP: a group of tests that measures the body’s metabolism. It consist of electrolyte, blood sugar levels, liver and kidney function tests.
ECG: assess the electrical activity of the heart muscles.
Chest x-ray: evaluate the trachea, lungs, heart and surrounding structures for any underlying pathology.
Assessment
Coronary artery disease with stable angina (I25.111): it is caused by narrowing or blockage of the coronary arteries secondary to build-up pf fatty materials inside the artery. Risk factors consists; hypertension, high cholesterol levels, diabetes and family history. The clinical presentation include; chest pain and shortness of breath especially on exertion (Rai Dilawar Shahjehan & Bhutta, 2022)Focused Note For Chest Pain Assignment Paper. A stable angina refers to chest pain or discomfort that is associated with emotional stress or physical activity and occurs due to a decrease of blood flow to the heart muscle.
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Congestive heart failure (428.0): occurs when the function of the heart is inadequate to meet the body needs. Predisposing risk factors include; diabetes, coronary artery disease, hypertension, alcohol intake and others (Malik et al., 2022). Clinical presentation include; chest pain, easy fatigability oedema and others.
Aortic aneurysm (I71.9): an abnormal bulging and enlargement of the lining of the aorta (Mathur et al., 2016). It mainly presents with difficulty in breathing, cough, and pain in the chest, jaw and upper back.
References
Malik, A., Brito, D., Sarosh Vaqar, & Chhabra, L. (2022, May 22). Congestive Heart Failure. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/
Mathur, A., Mohan, V., Ameta, D., Gaurav, B., & Haranahalli, P. (2016). Aortic aneurysm. Journal of Translational Internal Medicine, 4(1), 35–41. https://doi.org/10.1515/jtim-2016-0008
Rai Dilawar Shahjehan, & Bhutta, B. S. (2022, February 9). Coronary Artery Disease. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564304/ Focused Note For Chest Pain Assignment Paper
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:
- Location
- Quality
- Quantity or severity
- Timing, including onset, duration, and frequency
- Setting in which it occurs
- Factors that have aggravated or relieved the symptom
- Associated manifestations
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors. Focused Note For Chest Pain Assignment Paper
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Include last Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
Cardiovascular/Peripheral Vascular:
Respiratory:
Gastrointestinal:
Musculoskeletal:
Psychiatric:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things. Focused Note For Chest Pain Assignment Paper
Cardiovascular/Peripheral Vascular: Always include the heart in your PE.
Respiratory: Always include this in your PE.
Gastrointestinal:
Musculoskeletal:
Neurological:
Skin:
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Diagnostic Test/Labs: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses with rationale for each one documented OR ones that were mentioned during the SH assignment.
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled Focused Note For Chest Pain Assignment Paper