Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Assignment

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Assignment

Episodic/Focused SOAP Note

Patient Information:

S.

CC: “I have been having some troubling chest pain in my chest now and then for the past month.”

HPI: Brian Foster, a Caucasian male who is 58 years old, comes in complaining of chest pain that he says has been occurring on and off over the course of the previous month. He reports that he feels a tightness and pain in his chest just above his heart, but does not spread. On a scale from one to ten, he places the sporadic chest pain that he has at a five. He. explains that he was working in the yard when he felt the ache for the first time. The second time he had the ache, he was making his way up the stairs at his place of work. The patient indicates that physical activity makes the discomfort worse, although resting down provides some relief. He claims that he did not use any painkillers in order to cope with the discomfort. He went on to say that the pain had struck him three times in the preceding month. The discomfort is consistent and lasts for a few minutes each time. He denies shortness of breath, cough, nausea, or vomiting Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Assignment.

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Current Medications:

Omega-3fish oil 1200mg PO BID

Tylenol

Atorvastatin 20 mg PO QHS

Lisinopril 20mg PO QD

Allergies: Pt reports codeine allergy- nausea and vomiting are its symptoms.

PMHx: Reports history of hypertension and high cholesterol. Immunizations are current. Reports being heterosexual. Denies history of surgeries.

Past Surgical History (PSH): Denies surgical history

Sexual/Reproductive History: Married, one child.

 

 Personal/Social History: The patient typically drinks two to three beers throughout the course of the weekend. Denies ever having used tobacco or illegal substances. He claims there are no sources of stress. He used to ride his bike frequently before it was stolen, but he does not presently participate in any kind of regular exercise or other physical activity. He claims to maintain a balanced and nutritious diet.

Immunization History: childhood immunizations are current. Flu vaccine received last year.

Significant Family History: The patient’s father has been diagnosed with the conditions of hypertension, hyperlipidemia, and obesity. At the age of 75, he passed away from colon cancer. Both diabetes and high blood pressure are conditions that affect his mother. Diabetes and high blood pressure are also conditions that have been identified in his sister. He claims that his brother passed away in a vehicle accident when he was 24 years old, and that his maternal grandpa passed away from a heart attack when he was in his fifties.

ROS:

GENERAL:  Denies fever, chills, fatigue, weight change,  or changes in appetite.

CARDIOVASCULAR:  Reports chest pain in the middle of the chest. Denies chest pressure, palpitations or edema.

RESPIRATORY:  Denies wheezing, cough, or shortness of breath.

GASTROINTESTINAL:  Denies nausea, vomiting, constipation, abdominal pain, or diarrhea.

MUSCULOSKELETAL:  Denies back, muscle pain, joint pain, stiffness or injury.

PSYCHIATRIC:  Denies history of depression or anxiety.

O.

Physical exam:

Vital signs: BP 146/90, Pulse 104, O2 sat 98%, RR 19, Temp 36.7C, Weight: 197lbs, Height: 5’ 11”

Cardiovascular/Peripheral Vascular: S1, S2, and S3 noted, with gallop. Right carotid with thrill and bruit. No thrill or bruit noted in left carotid.

Respiratory: right and left posterior lower lobes with fine crackles.

Gastrointestinal: Normoactive bowel sounds. No blood in the stool.

Musculoskeletal: back curvature normal

Neurological:  5/5 strength in all extremities

Skin: No rash or tenting noted.

 Diagnostic Test/Labs:

EKG- Normal rate and rhythm. No ST elevation.

A.

Angina Pectoris: This disease serves as the main diagnosis for this particular patient. It is defined by a persistent feeling of pressure, tightness, or pain in the chest that occurs over the course of time. The discomfort is brought on by effort or by engaging in physical activity, and it is alleviated by sitting or lying down (Gillen & Goyal, 2021). The patient has been diagnosed with this illness because he has complained of chest discomfort that is worse by physical activity but eased when at rest.

Coronary artery disease: This is a possible diagnosis for the patient in question due to the fact that it is marked by certain symptoms, including a pressing sensation similar to that of chest discomfort (Malakar et al., 2019). On the other hand, this is not a possibility since the patient reported that the discomfort does not travel to the back Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Assignment.

GERD: This illness makes it difficult to swallow and is characterized by a burning feeling in the chest in addition to chest discomfort (Clarrett & Hachem, 2018). Because the patient claims they have no trouble swallowing, it may be concluded that he does not have this illness.

Acute Pericarditis: This diagnosis is also appropriate for the patient. The chest discomfort associated with this illness is described as being stabbing and intense, and it comes on quite suddenly (Ismail, 2020). However, this ailment is not likely to be the cause of the client’s discomfort since it does not come on suddenly.

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Shadow Health Digital Clinical Experience Focused Exam: Chest Pain

Documentation

SUBJECTIVE DATA:
Chief Complaint (CC): “I have been having some troubling chest pain in my chest now and then for the
past month.”
HPI: The client Brian Foster is a 58-year-old, Caucasian man who presents with chest pain intermittently
which he reports has been going on for the past month. He describes the pain as an uncomfortable and
tight feeling in the chest above his heart, which does not radiate to the back or arms. He rates the
intermittent chest pain as 5 on a scale of 10 when is occurs. B.F reveals that he first experienced the
pain while working in the yard. The second time he experienced the pain while climbing stairs at work.
The client reports exercise as an aggravating factor while lying down relieves the pain. He denies using
any pain relievers to manage the pain. He added that he experienced the pain three times in the past
month. Every time the pain lasts for some minutes. He currently denies any N/V/D.

Medications:
1. Atorvastatin 20 mg orally once a day,
2. Lisinopril 20mg orally every day,
3. Omega-3 fish oil 1200mg orally twice a day.
4. Tylenol for managing headaches.
Allergies: Reports being allergic to codeine. “It makes me nauseous, and I vomit.”
Past Medical History (PMH): The client reports a history of hypertension and high cholesterol, which
were diagnosed last year.
Past Surgical History (PSH): The client denies any surgery.
Sexual/Reproductive History: Married with a daughter.

Personal/Social History: The client consumes 2-3 beers on the weekend. Denies tobacco or illicit drugs
use. He denies any stressors. He engaged in bike riding until his bike was stolen, but currently does not
engage in exercise or physical activities regularly. He reports eating a healthy diet. The client reported

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undergoing stress tests and EKGs annually and the results were normal. He reports visiting his primary
care provider every six months.

Immunization History: The client’s childhood immunization are updated. He received the flu vaccine last
year.

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Significant Family History: The client reports that his father had been diagnosed with hyperlipidemia,
hypertension, and obesity. He died of colon cancer at 75 years. His mother is 80yo and has hypertension
and type 2 diabetes (T2DM). Similarly, his sister has been diagnosed with T2DM and hypertension. He
adds that his brother died in a car accident at age 24 and his maternal grandfather died of a heart attack
in his mid-fifties.

Review of Systems:
General: Client is dressed appropriately for the visit. He is anxious about the pain in his chest but
otherwise no distress noted. He denies fever and N/V/D.
Cardiovascular/Peripheral Vascular: Currently, the client denies chest pain. He reposts tightness in the
chest that occurred last month. He added that chest pain occurs while engaging in activity such as yard
work and walking up stairs. Reports pain reduces upon lying down.
Respiratory: Denies sputum production or cough.
Gastrointestinal: Denies constipation, nausea, or vomiting.
Musculoskeletal: Denies joint pain, back pain, or joint swelling.
Psychiatric: Denies insomnia or suicidal thoughts.
OBJECTIVE DATA:
Physical Exam:
Vital signs: BP 146/90, Pulse 104, O2 sat 98%, RR 19, Temp 36.7C, Weight: 197lbs, and Height: 5’ 11”
Cardiovascular/Peripheral Vascular: Bruit and thrill noted to right carotid , but no bruit and thrill note Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Assignment
to left carotid. S1, S2, and S3 auscultated, gallop noted.
Respiratory: Fine crackles noted to right and left posterior lower lobes. Denies cough or SOB.
Gastrointestinal: No blood in the stool. No constipation.
Musculoskeletal: Normal back curvature.
Neurological: Motor is 5/5 throughout
Skin: No abnormalities noted.

© 2021 Walden University
Diagnostics:
EKG: No ST changes. Normal Sinus was detected.
ASSESSMENT:
1. Angina Pectoris: This condition is the primary diagnosis for this client. It is characterized by
pressure, tightness, or discomfort in the chest that recurs over time. The pain is prompted by exertion or
physical exercise and relieved by lying down (Ford & Berry, 2020). The client has this condition since he
reported chest pain that increases with exercise and reduces upon lying down.
2. Coronary artery disease: This is another potential diagnosis for this client since it is
characterized by some reported symptoms, including pressure like chest pain, which radiates to the left
shoulder (Ford & Berry, 2020). However, it is ruled out since the client stated that the pain does not
radiate to the back.
3. GERD: This condition is characterized by a burning sensation in the chest and chest pain,
making swallowing difficult (Clarrett & Hachem, 2018). This condition is ruled out since the client denies
difficulty swallowing.
4. Acute Pericarditis: The client also qualifies for this diagnosis. This condition is characterized by
stabbing and sharp chest pain, which occurs quickly (Ismail, 2020). Nonetheless, this condition is ruled
out since the client’s pain does not occur quickly.
References
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri
medicine, 115(3), 214.
Ford, T. J., & Berry, C. (2020). Angina: contemporary diagnosis and management. Heart, 106(5), 387-398.
Ismail, T. F. (2020). Acute pericarditis: update on diagnosis and management. Clinical Medicine, 20(1),

Will you please re word his soap note but use the same info to prevent plagiarism when being submitted… thank you

References

Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri medicine, 115(3), 214. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140167/

Gillen, C., & Goyal, A. (2021). Stable Angina. StatPearls.

Ismail, T. F. (2020). Acute pericarditis: Update on diagnosis and management. Clinical Medicine, 20(1), 48-51. https://doi.org/10.7861/clinmed.cme.20.1.4

Malakar, A. K., Choudhury, D., Halder, B., Paul, P., Uddin, A., & Chakraborty, S. (2019). A review on coronary artery disease, its risk factors, and therapeutics. Journal of Cellular Physiology, 234(10), 16812-16823. https://doi.org/10.1002/jcp.28350 Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Assignment