BRIAN FOSTER-SHADOW HEALTH-Discussion six

BRIAN FOSTER-SHADOW HEALTH-Discussion six

Using the information from the examination of Brian Foster, Chest Pain in Shadow Health, Focused Exam, write a SOAP note and copy it into the Discussion for Module VI.  Your response discussion should be a review of one other student’s SOAP note, commenting on identifying areas that you did not include in your own SOAP note and discussing why inclusion of those areas may be important in reaching an appropriate assessment.Post your initial response and respond to one student. Scholarly written, APA formatted, and referenced.  A minimum of 2 references

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SUBJECTIVE DATA

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 midsternal as location. Describes pain as “tight and uncomfortable” upon movement or exertion. Mentioned an episode upon going up the stairs to bed. Most recent episode was three days ago after eating a large restaurant dinner. Denies radiation. Pain lasts for “a few” minutes and goes away when he rests. States “It has never gotten ‘really bad'” so he didn’t think it was an emergency, but is concerned after three episodes in one month and wants his heart checked out. Last physical was 1 year ago but says he hadn’t been checked out for several years prior. His regular diet includes grilled meat, some sandwiches, and vegetables. Reports grilling between 4-5 times a week, usually red meat. Has fast food for lunch on busy days. 1-2 cups of coffee a day. Denies coughing, shortness of breath, indigestion, heartburn, jaw pain, fatigue, dizziness, weakness, nausea, vomiting, and diarrhea. Denies chest pain at time of interview. No history of anxiety or depression.

General Survey: Alert and oriented, with clear speech. Sitting comfortably in no acute distress. • Cardiac: S1, S2, without murmurs or rubs. S3 noted at mitral area. No swelling or fluid retention present. • Peripheral Vascular: No JVD present. JVP 3 cm above sternal angle. Left carotid no bruit. Right side carotid bruit. Right carotid pulse with thrill, 3+. Brachial, radial, femoral pulses without thrill, 2+. Popliteal, tibial, and dorsalis pedis pulses without thrill, 1+. Cap refill less than 3 seconds in all 4 extremities. • Respiratory: Breathing is quiet and unlabored. Breath sounds are clear to auscultation in upper lobes and RML. Fine crackles in posterior bases of L/R lungs. • Gastrointestinal: Round, soft, non-tender with normoactive bowel sounds in all 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. Gross cranial nerves 2-12 bilaterally and grossly intact. • Skin: Warm, dry, pink, and intact. No tenting and no sweating. • Musculoskeletal: Moves all extremities. • Psych: Normal affect, cooperative, good eye contact. • EKG (interpretation): Regular sinus rhythm. No ST changes. • 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

Based on the abnormal findings during cardiovascular and respiratory auscultation, my differentials include coronary artery disease with stable angina; congestive heart failure; carotid disease; aortic aneurysm; pericarditis; or GERD.

PLAN

Mr. Foster should receive a 12-lead ECG, chest x-ray, and lab workup (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1C, lipid profile, and liver function tests) to confirm a diagnosis. He should be referred for an echocardiogram, exercise stress test, and carotid dopplers as well as a consult with a vascular surgeon for carotid evaluation. Mr. Foster should be prescribed diltiazem and a diuretic in addition to his daily lisinopril and atorvastatin. If needed, add an ACE inhibitor to manage his hypertension and PRN nitroglycerin for chest pain that does not subside with rest.

 

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