NR 509 Shadowhealth Wk 4 Chest Pain Model

Document: Provider Notes

Student Documentation	Model Documentation
Subjective HPI: Mr. Foster is a 58 year old male Caucasian that presents in clinic today with chest pain. Stage 3 episodes of chest pain in the last month (onset: 1 month). Level of pain is a 5/10 at its worst. Denies current chest pain/tightness. localized midsternal chest pain that does not radiate. Describes the pain as “tight and uncomfortable”. One episode after yard work, 1 episode after climbing the 5 flights of stairs at work, 1 episode after eating dinner out with his wife. States the pain goes away after a few minutes with rest. Denies treating pain with any medications. ROS: General- denies fever chill or night sweats. Denies any weakness, fatigue, or dizziness. Patient states he has gained about 15 or 20 lb over 2 years. No formal exercise routine. No formal diet. HEENT- Denies nasal drainage, sore throat, or trouble swallowing. Denies vision changes/ does not wear glasses or contacts. all teeth intact Skin: denies any lesions or discolorations Respiratory- denies shortness of breath or cough. Denies dyspnea on exertion. Denies recent chest x-ray. GI- has had some bouts of infrequent diarrhea, none today last BM this morning was reported normal. Denies constipation. Denies nausea or vomiting. Denies any heartburn. Cardio- denies palpitations/edema/angina. Current medical history- hypertension and hyperlipidemia dx 1 year ago. Last doctor visit was 3 months ago for a physical. Current on immunizations: flu shot yearly/ current tetanus booster. Denies recent chest xray, States he has an EKG and stress test done annualy (normal) Current Medications- 20mg Lipitor at bedtime (last dose yesterday evening) Metoprolol 100mg daily (taken today) Fish oil.Omega 3- (last dose this morning) Allergies: Codeine (nausea/vomiting) Social history- lives at home with his wife of 27 years, and daughter who is in college. has not had a formal exercise routine in 2 years (used to ride his bike daily before it was stolen), no formal diet regimen but does watch his sodium and fat intake, drinks 2 cups of coffee daily, denies tobacco use, no illicit drug use, drinks two to three beers on the weekends. Family history: daughter- Asthma Father- Deceased, colon cancer, high blood pressure, hyperlipidemia Mother- diabetes, high blood pressure Sister- diabetes, high blood pressure Maternal grandmother- deceased, breast cancer Maternal grandfather- deceased, heart attack Paternal grandmother- deceased, pneumonia Paternal grandfather- deceased no health history	Pt. reports “I have been having some troubling chest pain in my chest now and then for the past month.” Experiencing periodic chest pain with exertion such as yard work as well as with overeating. Points to midsternum as location. Describes pain as “tight and uncomfortable.” Denies radiation. Pain lasts for “a few” minutes and goes away when he rests. Most recent episode was three days ago after eating a large restaurant dinner. States “It has never gotten ‘really bad’” so didn’t think it was an emergency, but is concerned after three episodes in one month and wants his heart checked out. Reports mild cramping in legs with activity. Denies shortness of breath, indigestion, heartburn. Denies chest pain at this time.
Objective Mr. Foster is a 58 year old Caucasian male that appears and no acute distress sitting on exam table, is alert and oriented, maintains good eye contact during interview, and answers all questions appropriately/ good historian. Vitals BP 146/90 HR 104 SpO2 98% room air RR 19 Temp 36.7C General appearance: in no acute distress, well groomed, clear speech. Skin: No lesions or discoloration noted, no tenting Cardiac: no visible abnormalities. S1 and S2 normal, audible S3 noted at the mitral area with PMI displaced laterally less than 3cm, brisk and tapping. Peripheral vascular: Right sided Carotid Bruit noted/ palpable thrill 3+, No bruit heard over Left Carotid, no palpable thrill 2+. No abdominal aortic, renal, iliac, or femoral bruit heard. JVP 3 cm above sternal angle. Brachial, radial, femoral pulses without thrill all 2 + bilaterally. Dorsalis pedis, posterior tibialis, popliteal without thrill 1+ bilaterally. Capillary refill is less than 3 seconds in all extremities. EKG normal with no ST-elevation Respiratory: breath sounds present in all areas, clear to auscultation in Upper lobes, fine crackles in posterior lower lobes bilaterally. Gastrointestinal: no visible distortions, rounded, soft and non-tender to light and deep palpation, bowel sounds present in all four quadrants, liver palpable, spleen nonpalpable, no friction rub, tympany percussed throughout, kidneys nonpalpable bilaterally.	• General Survey: 58 year old male is alert and oriented, with clear speech and in no acute distress. • Cardiac: S1, S2, without murmurs or rubs. PMI displaced laterally. S3 noted at mitral area. • Peripheral Vascular: Right side carotid bruit. JVP 3cm above sternal angle. Right carotid pulse with thrill, 3+. Left carotid pulse without thrill, 2+. Brachial, radial, femoral pulses without thrill, 2+. Popliteal, tibial, and dorsalis pedis pulses without thrill, 1+. Cap refill less than 3 seconds – 4 extremities. • Respiratory: Breathing is quiet and unlabored. Breath sounds are clear to auscultation in upper lobes and RML. Fine crackles/rales in posterior bases of L/R lungs. • Gastrointestinal: Round, soft, non-tender with normoactive bowel sounds in 4 quadrants; no abdominal bruits. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. • Neuro: Alert and oriented x 3, follows commands, moves all extremities. • Skin: Warm, dry, pink, and intact. No tenting. • EKG (interpretation): Regular sinus rhythm. No ST changes.
Assessment Occulsion and stenosis of right carotid artery New onset Congestive Heart Failure Hypertension Angina Pectoris Chest pain with activity/disappears with rest, ill regulated blood pressure, audible S3 with displaced PMI, bruit over right carotid artery, fine crackles/fluid in posterior lower lobes bilaterally.	Coronary artery disease with stable angina. Differential diagnoses include congestive heart failure, carotid disease, aortic aneurysm, pericarditis, or GERD
Plan Diagnostics: Chest X-ray, Echocardiogram, stress test, carotid dopplers, CMP (include LFTs/Renal), Cardiac enzymes, CBC, BNP, fasting lipids, A1C, Thyroid panel. Medication: Dependent upon lab results: Diuretic therapy, decrease Lopressor to 50mg daily, add Lisinopril 10mg PO dialy, add ASA 81mg PO daily, Continue Lipitor 20mg daily, continue fish oil daily add PRN sublinguial Nitroglycerin to take if angina does not disappear with rest. Education: Educate Mr. Foster on implementing lifestyle modification such as implementing an appropriate exercise and diet regimen. Home monitoring of blood pressure Discuss signs and symptoms of myocardial infarction and when to seek emergent care Monitor daily weights Decrease sodium intake Advise to go to ER if symptoms worsen or are unrelieved with rest (pain unrelieved with rest or associated with radiation/ dizziness/ nausea/ vomiting/ diaphoresis/SOB/ Referral: Referral to cardiac specialists/ Cardiology. Follow up: Seek immediate care if your symptoms worsen or if they are unrelieved by rest. Follow up in one week at clinic for eval and follow up.	Diagnostics • He should also receive a chest x-ray • Fasting lab workup including cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1C, lipid profile, and liver function tests to confirm a diagnosis Medication • Collaborate with cardiology specialist to prescribe diuretic therapy, titrate off Lopressor and transition to ACE inhibitor for management of blood pressure • Upon future evaluation with cardiology, consider PRN nitroglycerin for chest pain that does not subside with rest Education • Educate patient regarding exercise, diet, and lifestyle modifications Referral/Consultation • Expedited referral to cardiology for evaluation and treatment, an echocardiogram, exercise stress test, and bilateral carotid doppler examination • Mr. Foster may need an additional consult with a vascular surgeon for carotid evaluation Follow-up Planning • Educate Mr. Foster to seek immediate medical attention if chest pain returns, gets worse, and is associated with radiation, diaphoresis, shortness of breath, nausea/vomiting, or dizziness/faintness • Return to clinic in 5-7 days for evaluation and follow up

NR 509 Shadowhealth Wk 4 Chest Pain Model

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NR 509 Week 2 Alternate Writing Assignment, Respiratory

Purpose

As a family nurse practitioner, you must possess excellent physical assessment skills. This alternative writing assignment mirrors the discussion content of the debriefing session and will allow the student to expand their knowledge of physical health assessment principles specific to the advanced practice role.

Course Outcomes

This assignment is guided by the following Course Outcomes (COs):

Apply advanced practice nursing knowledge to collecting health history information and physical examination findings for various patient populations. (PO 1, 2)
Differentiate normal and abnormal health history and physical examination findings. (PO 1, 2)
Adapt health history and physical examination skills to the developmental, gender-related, age-specific, and special population needs of the individual patient. (PO 1, 2)

The purposes of this assignment are to: (a) identify and articulate advanced assessment health history and physical examination techniques which are relevant to a focused body system (CO 1), (b) differentiate normal and abnormal findings with regard to a disease or condition that impacts the body system (CO 2), and (c) adapt advanced assessment skills if necessary to suit the needs of specific patient populations (CO 4).

NOTE: You are to complete this alternative writing assignment ONLY if you had not participated or do not plan to participate in a debriefing session for the given week.

Due Date: This alternative written assignment is due no later than the Sunday of the week in which you did not attend the weekly debriefing session. The standard MSN Participation Late Assignment policy applies to this assignment.

Preparing the Paper:

Select a focused body system from the weekly lesson which corresponds with the week of the written assignment.
Carefully read and review the selected body system in your course textbooks.
Incorporate at least one scholarly peer-reviewed journal article that relates to the body system. It may be useful to identify an article that relates to a disease that impacts the body system.
The paper must clearly articulate the relevance of advanced physical assessment skills, techniques, application of advanced practice knowledge, and assessment modification (when necessary) to accommodate for specific patient populations.
Provide concluding statements that should summarize key points of the overall assignment content.
In-text citations and reference page(s) must be written using proper APA format (6th edition).

NR 509 Shadowhealth Wk 4 Chest Pain Model