Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
Chief Complaint (CC):
A 58 years-old Caucasian male patient complained of having chest pain for the past month. The patient stated pain to be 5 out of 10. The pain, he says, is tight and uncomfortable in the middle of his chest. He denies taking any pain relievers.
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:
A 58 years old Caucasian male presents symptoms of chest pain as described below
1. Location: Report pain in the center of his chest
2. Quality: The patient describes the pain as tight and uncomfortable
3. Quantity or severity: Patient current pain is 0 out of 10. pain severity at its worst is 5 out of 10
4. Timing, including onset, duration, and frequency: Reports experiencing chest pain. Each pain episode lasted several minutes. report 3 pain episodes in the last month
5. Setting in which it occurs: The Pain occurs during activities.
6. Factors that have aggravated or relieved the symptom: reports Pain is exacerbated by activity; reports pain occurred with yard work and when taking the stairs. Pain relief is achieved through a brief period of rest. denies using pain relievers to treat chest pain
7. Associated manifestations: 3 chest pain that does not radiate, pain episode lasted for several minutes, pain in the center of the chest that is tight and uncomfortable
Medications:
Lisinopril 20mg by mouth daily
Atorvastatin 20mg by mouth daily at bedtime
Omega-3 fish oil 1200mg by mouth twice daily
Ibuprofen
Allergies
Codeine: causes nausea and vomiting
Past Medical History (PMH):
High blood pressure- stage 2 diagnosed 1 year ago
Hyperlipidemia- diagnosed 1 year ago
Past Surgical History (PSH): No surgeries
Sexual/Reproductive History: Heterosexual
Personal/Social History: The patient is a nonsmoker who drinks 2-3 beers on weekends, socializes, denies using illicit drugs, is reasonably healthy, and was an avid bike rider until his bike was stolen. wishing to resume riding.
Immunization History: T dap 10/2014, influenza vaccine this season
Significant Family History: Include history of parents, Grandparents, siblings, and children
Father: history of Hypertension, hyperlipidemia, obesity. died of colon cancer at the age of 75.
Mother: history of type 2 diabetes, Hypertension age 80
Brother: died in a motor vehicle accident age 24
Sister: history of type 2 diabetes, hypertension, age 52
Maternal Grandmother: died of breast cancer age 65
Maternal Grandfather: Died of a heart attack age 54
Paternal grandmother: died of pneumonia at age 78
Paternal grandfather died of old age at age 85
Son: health, age 26
Daughter: Asthma age 19
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: The patient denies weight loss, sleep disturbance, or syncope.
Head: Denies headache and dizziness
Eyes: no problem with vision
Ears: absent of ear infection, no use of hearing aid
Nose: no nasal drainage
Mouth: the patient has his own teeth
Neck: denies sore throat, neck pain absent, right side carotid bruit, no palpable masses, no tracheal deviation.
Breast: no masses present
Cardiovascular/Peripheral Vascular: heart sounds s1, s2,s3 audible, extra heart sound
Gallop. Palpable pulses upper and lower extremities .no edema noted
Respiratory: breath sounds clear at the apex with diminished bases and fine crackles found at bilateral lower lobes
Gastrointestinal: denies constipation and diarrhea, appetite is good and normal digestion.
Genitourinary: no urinary incontinence, no retention of urine, and no erectile dysfunction
Musculoskeletal: denies joint and muscle pain, range of motion present
Psychiatric: no psych history, denies depression.
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: BP: 146/90, RR: 19, HR: 104, O2 Sat: 98% RA Ht: 5ft 11 inches, Weight:197 lbs,
Temp 36.7
General: Patient is A/O X4 to person, place, time, and situation, well-groomed, pleasant, and cooperative with care. able to answer questions appropriately.
Head: no sign of trauma noted
Eyes: Adequate vision, no glasses or lens present
Ears: no present use of hearing aid, no ringing in the ears
Nose: no bleeding noted, able to breathe without difficulty
Mouth: no dentures present, mouth is moist and pink.
Neck: no jugular vein distension, trach at midline, bruit on the right side
Cardiovascular/Peripheral Vascular: heart sounds s1, s2,s3 audible, extra heart sound
Gallop. Palpable pulses upper and lower extremities .no edema noted
Respiratory: breath sounds clear at the apex with diminished bases and fine crackles found at bilateral lower lobes Report chest tightness,
Gastrointestinal: Abdomen soft non-tender, liver palpable 1cm below the right costal margin, bowel sounds normoactive, denies constipation and diarrhea. absent of nausea and vomiting
Musculoskeletal: Denies pain, and good muscle tone
Neurological: speech clear, Alert, and oriented x4.
Skin: Clean, dry, and intact, appropriate for race.
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.