Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

SUBJECTIVE DATA:

Chief Complaint (CC): Tight and uncomfortable chest pain

History of Present Illness (HPI): The client is a 50-year-old male who presented with complaints of chest pain over the past one mother. The pain started one month ago. He explains the pain as tight and uncomfortable over his heart, but the pain is not radiating.

He rates current pain at 0/10, but at times it is at 5/10. The pain episodes last about three minutes, and he has had three episodes in the last month. These episodes occur at home and work. The pain is exacerbated by exercise and physical activities, and lying relieves little.

Medications: PO Lisinopril 20mg QID, PO atorvastatin 20mg qhs

Allergies: Codeine allergy

Past Medical History (PMH): Was diagnosed with HTN stage II 2 years ago and diagnosed with hyperlipidemia a year ago. Normal results after a stress test a year ago.

Past Surgical History (PSH): Denies any surgical history

Sexual/Reproductive History: Monogamous family man. He is married to his wife of 27 years. Reported an STD before marriage

Personal/Social History: Reports taking 2-3 beers on weekends. Denies any tobacco or any illicit drug use

Immunization History: Up to date with immunizations. #1 2/02/2022 Pfizer biotechnology vaccine #2 12/09/2022

Significant Family History: Father succumbed to colon cancer at 75 and was hypertensive, obese, and hyperlipidemic. Mother, 80, has type 2 diabetes and is hypertensive. Sister, 52, type 2diabetes and hypertensive. Maternal grandmother succumbed to breast cancer at 65. Maternal grandfather succumbed to heart attack at 54. Paternal grandmother succumbed to pneumonia at 78. Paternal grandfather died at 85 with no known health illness and died of old age.

Review of Systems:

General: Denies fever, child, and sweats. Reports 20lb weight gain over the last few years

Cardiovascular/Peripheral Vascular: Denies vertigo, orthopnea, edema, feelings of heart racing, skipping beats, or feeling flushed

Respiratory: Reports shortness of breath when walking or exercising. Denies any cough, runny nose, congestion, or hemoptysis

Gastrointestinal: Denies abdominal pain, bowel or bladder routine changes, diarrhea, constipation, or hemoptysis

Musculoskeletal: Denies any muscle weakness, reports a normal gait and no changes in gait and balance

Psychiatric: Denies mood changes, depression, anxiety, or any other mental illness

OBJECTIVE DATA:

Physical Exam:

Vital signs: Bp 141/91, P 104, RR 19; WT 195; HT 5’11’

General: Patient is alert, with no signs of distress. Has a pleasant and calm mood, has good hygiene

Cardiovascular/Peripheral Vascular: Tachycardic; P 104, symmetrical chest rising with breathing, laterally displaced PMI. S3 auscultated MCL 5^th ICS. S4, murmurs, or rub not auscultated. Acynotic lips and fingers, with no clubbing. Right carotid bruit +3 thrill, left carotid bruit +2, brachial arteries- +2 no thrill radial arteries +2 no bruit, popliteal arteries +1 thrill no bruit, and femoral, ilia, and renal arteries pulse present with no bruits. Jugular vein distention about 4cm above the sternal angle.

Respiratory: Bilateral lower lobes inspiratory crackles. Vesicular breath sounds are present. No SOB, no pain on palpation, Resonant sound on percussion, with a dull sound on percussion of the lower lobes

Gastrointestinal: Abdomen Globular and symmetric, bowel sounds auscultated in all four quadrants. Denies pain on palpation tympanic sound, no distention. Liver palpable, no organomegaly. Kidneys are unpalpable. Patient reports no pain on deep and light palpation.

Musculoskeletal: Steady gait, balances without assistance, appreciable muscle tone, grip strength appreciable in both hands

Neurological: Well-oriented to person, place, time, and situation. Coherent answers to questions posed, no changes in speech. PERRLA

Skin: Warm and dry skin. No lesions, rashes, or swellings and no skin breakages

Diagnostic Test/Labs:

A chest X-ray- to study the structure of the heart and diagnose or rule out structural defects

An electrocardiogram- to rule out or diagnose abnormality with the electric cardiac function such as unstable angina

Cardiac stress test and troponin level to determine the involvement of the heart and effects on normal cardiac rhythms

ASSESSMENT: The priority diagnosis is unstable angina. Brief pain episodes characterize unstable angina, usually lasting a few minutes, squeezing, pressure, and chest tightness, and even during rest (Wadhera et al., 2019). Unstable angina often results from the blockage of blood vessels interfering with blood supply to the heart. The patient experiences pain at least thrice a month, lasting a few minutes, with pain rated 5/10.

The risk factors for the disease include hypertension, obesity, and hyperlipidemia in this patient. The patient presents with tachycardia, a BPM of 104, chest pain at 5/10, with current pain at 0/10. PMIS is laterally displaced, tapping, and brisking: less than three cm. S3 auscultated at the 5^th ICS, no S4, murmurs, or rub.

Acynotic lips and toes with no clubbing. Right carotid bruit present +3 thrill with no other arterial bruits. The jugular vein distended about 4cm above the sternal angle. Inspirator crackles in the lower lobes. The patient also presents with difficulty exercising and physical activities.

Differential Diagnosis 1: CCF

Congestive Cardiac Failure results from progressive heart damage with multiorgan systems involvement (Malik et al., 2021). The patient presents with S3 heart sound, acute pulmonary edema, cardiomegaly, JVD, orthopnea, and tachycardia (120bpm). However, the carotid bruits, JVD, and periodic chest tightness rule out the disease.

Differential Diagnosis 2: Pneumonia

Patients with pneumonia present with cough, chest pain, fever, fatigue, and crackles due to fluid accumulation in the lung lobes (Grief & Loza, 2018). Pneumonia presents with continuous chest pain with other respiratory symptoms such as hemoptysis and coughing green or yellow phlegm. This patient presents with crackles on inspiration and pulmonary edema but has no cough or other respiratory symptoms, ruling out the disease.

Differential Diagnosis 3

Stable angina is an ischemic condition that results from exertion or exercise. The features include shortness of breath, and periodic chest squeezing or tightness, aggravated by walking or exercise (Gillen & Goyal, 2020). However, the symptoms must have lasted for at least two months for a definitive diagnosis (Joshi & De Lemos, 2021). In addition, the pain radiates to the neck and arm in stable angina. The patent denies any pain radiation hence ruling out the diagnosis.

The patient has current diagnoses of hypertension, diabetes, and hyperlipidemia, which are well controlled using lisinopril and atorvastatin, respectively. The blood pressure is slightly elevated, and the diabetes is well-controlled.

References

Joshi, P. H., & De Lemos, J. A. (2021). Diagnosis and management of stable angina: A review. JAMA, 325(17), 1765-1778. https://doi.org/10.1001/jama.2021.1527
Malik, A., Brito, D., Baqar, S., & Chibra, L., (2021). Congestive Cardiac Failure. StatPearl. StatPearls Publishing
Wadhera, R. K., Sukul, D., Secemsky, E. A., Shen, C., Gurm, H. S., Boden, W. E., & Yeh, R. W. (2019). Temporal trends in unstable angina diagnosis codes for outpatient percutaneous coronary interventions. JAMA Internal Medicine, 179(2), 259-261. https://doi.org/10.1001/jamainternmed.2018.5124

Grief, S. N., & Loza, J. K. (2018). Guidelines for the Evaluation and Treatment of Pneumonia. Primary Care: Clinics in Office Practice, 45(3), 485-503. https://doi.org/10.1016/j.pop.2018.04.001
Gillen, C., & Goyal, A. (2020). Stable Angina. In StatPearls [Internet]. StatPearls Publishing.