Focused Note Chest Pain - Brian Foster

Format for a Focused Note Necessary Components for the Subjective information: Date of encounter: April 14, 2020 Patient Name or initials: Brian Foster Informant: (Source of history/Reliability) The informant is the ...

Format for a Focused Note Necessary Components for the Subjective information: Date of encounter: April 14, 2020 Patient Name or initials: Brian Foster Informant: (Source of history/Reliability) The informant is the patient, seems reliable. Chief Complaint (CC): “I have been having some troubling chest pain in my chest now and then for the past month.” History of present illness (HPI): Mr. Foster is a 58 year old Caucasian male with a PMH of HTN and HLD who presents to the clinic with a chief complaint of chest pain described as tight, uncomfortable, non-radiating, midsternal chest pain rating 5/10 occurring three times in the last month lasting only a “couple of minutes”. The first occurrence was with yard work, the second occurrence was after walking up four flights of stairs at work, and the third occurrence was while out to dinner with his wife. The pain is worsened and more noticeable with movement and is relieved by rest. He denies taking any medication for the chest pain. He denies any current pain. He denies any shortness of breath, nausea, vomiting, diaphoresis, or dizziness. Allergies: Codeine (reports nausea and vomiting), denies food, environment, or latex allergy Medications: - Metoprolol (Lopressor) 100mg PO daily, last dose 0800 – (taken for HTN, prescribed for 1 year) - Atorvastatin (Lipitor) 20mg PO daily at bedtime, last dose 2200 yesterday – (taken for HLD, prescribed for 1 year) - Omega-3 Fish Oil 1200mg PO BID, last dose 0800 – (OTC supplement for HLD) - Ibuprofen PRN (per directions on bottle for various aches and pains, no more than 3 or 4 times monthly) Past History: Denies childhood illnesses, HTN Stage II diagnosed 1 year ago, HLD diagnosed 1 year ago, Denies surgical history Family History: : Father: deceased age 75 from colon cancer, hx HTN, HLD, obesity Mother: living age 80, hx T2DM, HTN, Brother: deceased age 24 from MVA Sister: living age 52, hx T2DM, HTN Maternal grandmother: deceased age 65 from breast cancer Maternal grandfather: deceased age 54 from MI Paternal grandmother: deceased age 78 from pneumonia Paternal grandfather: deceased age 85 from “old age” Son: living age 26, healthy, no known health issues This study source was downloaded by 100000831988016 from CourseHero.com on 05-06-2022 03:24:37 GMT -05:00 https://www.coursehero.com/file/60222696/Focused-Note-Chest-Pain-Brian-Fosterdocx/ Daughter: living age 19, hx asthma Personal and Social History: Reports receiving influenza vaccine this year, up to date with Tdap vaccine (last received 10/2014). Reports seeing his PCP every six months and has yearly cardiac stress tests. Reports EKG 3 months ago was normal and cardiac stress test last year was normal. Tobacco Use: Denies past or present tobacco use Alcohol and Drug use: Reports drinking 2-3 alcoholic beverages (beer) per week. Denies use of marijuana, cocaine, heroin, or other illicit drugs. Pertinent Review of systems (ROS): General: Patient reports gaining 15-20 lbs over the las couple of years. Reports anxiety due to recent chest pain. Denies fever, chills, fatigue, night sweats, palpitations, dizziness, lightheadedness or syncope. Respiratory: Denies history of cough, sputum production, wheezing or shortness of breath. Denies DOE. Denies pain on deep inspiration. Denies history of chest x-ray. Reports sleeping with only 1 pillow at night. Cardiovascular: Reports chest pain intermittently within the last month, denies current chest pain. Denies palpitations. Denies SOB. Reports past EKG has been normal (completed 3 months ago), past stress test has been normal (completed last year). Denies history of rheumatic fever, murmur, edema, or coagulopathy. Gastrointestinal: Denies recent changes in appetite. Denies heartburn, indigestion, nausea, vomiting, diarrhea, or constipation. Denies abdominal pain. Peripheral Vascular: Denies circulation problems or cyanosis. Denies leg pain or history of clots. Denies claudication. Denies swelling in legs. Denise varicose veins. Musculoskeletal: Denies back pain or any recent trauma. SUBJECTIVE REFLECTION: Reflect on your performance and interactions with the virtual patient. Include three additional questions you would ask the patient or informant and state how that information would assist you in formulating a diagnosis. 1. Does the pain occur early in the morning or wake you at night? - This pattern of pain has been linked to acute coronary syndrome so this information would have been helpful to rule out a diagnosis. 2. Does the pain increase with movement, cough, or deep inspiration? This study source was downloaded by 100000831988016 from CourseHero.com on 05-06-2022 03:24:37 GMT -05:00 https://www.coursehero.com/file/60222696/Focused-Note-Chest-Pain-Brian-Fosterdocx/ - This information would help to determine the likelihood of costochondritis or a PE. It could also help to differentiate between ischemic and non-ischemic chest pain (Bickley, 2017).. 3. Do you have any history of anxiety or panic disorder? - Patients with anxiety and panic disorders often describe chest pain on the anterior aspect of the chest as stabbing, sticking, or dull and aching, varying in severity. It can be fleeting or last up to hours or days and may be aggravated by exertional effort or emotional stress (Bickley, 2017). It would have been helpful to rule out these factors to eliminate anxiety as a source of Brian’s chest pain. Necessary Components for the Objective information: Document all findings, avoid the word negative or normal. It is important that you learn to deduce that the patient has no remarkable findings. Vital Signs: BP L arm 146/88, R arm 146/90, HR 104, RR, 19, O2 saturation 98% on room air, Temperature 36.7C orally, Pain 0/10 Height/Weight/BMI: 5’11”, 197 lbs., BMI 27.5 Physical Exam Constitutional/General survey: Mr. Foster is alert and oriented to person, place and time. His speech is clear, he maintains good eye contact and is sitting upright, unassisted, in no acute distress. He follows commands and answers questions appropriately. He moves all extremities x4. No acute signs of distress. Skin: Skin warm, pink, and dry per observation. No tenting per palpation. No diaphoresis noted. No edema present. No visible abnormal findings on inspection to bilateral hands and lower extremities. Thorax: Patient breathing unlabored. Symmetrical chest expansion anteriorly and posteriorly, no visible abnormal findings on inspection. Vesicular breath sounds auscultated anteriorly and posteriorly at right and left upper lobes, and right middle lobe anteriorly and posteriorly. Fine crackles noted on auscultation posteriorly in right and left lower lobes. Cardiovascular: Patient is negative for JVD in supine positioning, JVP measuring 3cm above sternal angle on inspection. R carotid artery bruit noted on auscultation and thrill noted 3+ on palpation. L carotid artery no bruit noted on auscultation, thrill noted 2+ on palpation. Heart sounds auscultated with patient lying supine, S1, and S2 noted without murmurs or rubs. S3 ventricular gallop noted at mitral area 5th left intercostal space midclavicular line with patient lying in left lateral recumbent position. PMI noted brisk and tapping at 5th intercostal space midclavicular line, less than 3cm, and displaced laterally on palpation. The apical impulse was then auscultated in the left lateral recumbent position, and again an audible S3 gallop could be heard. I would have had the patient sit upright and lean forward to auscultate along the left sternal border and apex for This study source was downloaded by 100000831988016 from CourseHero.com on 05-06-2022 03:24:37 GMT -05:00 https://www.coursehero.com/file/60222696/Focused-Note-Chest-Pain-Brian-Fosterdocx/ any additional murmurs or irregular heart sound