Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?  Shadow Health Digital Clinical Experience Focused Exam Chest Pain Documentation

In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.

In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
To Prepare
Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what history would be necessary to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

SUBJECTIVE DATA:

Chief Complaint (CC): chest pain

History of Present Illness (HPI): BF is a 58-year-old Caucasian man who suffers from recurring chest pain that has occurred three times in the last month. The patient reports that the pain is lessened by sitting or laying down and that it worsens with activity. The patient also claims that the discomfort is greater while they are standing or walking. There is a 5/10 degree of discomfort reported by the patient in each episode lasting around 5 minutes. When asked where he feels the pain, the patient says it is “tight and uncomfortable” in the centre of his chest. Denies the existence of pain that is spreading to the arm or back, as well as the neck. Denies having any breathing difficulties. The client is presently denying that he is experiencing any chest pain and rating their level of pain as 0 out of 10. Shadow Health Digital Clinical Experience Focused Exam Chest Pain Documentation

Medications:

Lisinopril 20mg daily

Omega-3 Fish Oil 1200mg BID

Atorvastatin 20mg QHS

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Allergies:

Codeine- nausea, vomiting,

Past Medical History (PMH):

Hyperlipidemia

Hypertension

Denies history of hospitalizations

Past Surgical History (PSH): Denies surgical history

Sexual/Reproductive History: Identifies as heterosexual and is in a monogamous relationship. Has two children.

Personal/Social History: Denies tobacco or illicit drug use. Reports occasional alcohol use.

Immunization History:

Tdap 10/2014.

Influenza 10/2021.

COVID-19 2021

Significant Family History:

Father- deceased from colon cancer, history of obesity, hypertension, and hyperlipidemia,

Mother – diabetes, Hypertension,

Sister- diabetes, hypertension

Paternal grandmother-died from pneumonia

Maternal grandfather-died from stroke.

Maternal grandmother-died from breast cancer.

Review of Systems:

General: Denies weight change, fatigue , or fever.

Cardiovascular/Peripheral Vascular: Reports pain in the middle of the chest. Denies palpitations or swelling.

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

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

Musculoskeletal: Denies muscle pain, or injury. Denies joint pain or injury. Denies history of sprains or fractures.

Psychiatric: Denies history of anxiety, depression or other mental illnesses.

OBJECTIVE DATA:

Physical Exam:

Vital signs: 146/90, P-104, R-19, T-36.7C. Ht- 5’11. Wt 197lbs. BMI 27.5

General: Alert and oriented x 4. Appears well-dressed, well-nourished, and well-groomed.  Able to maintain eye contact. Cooperative. Clear and coherent speech

Cardiovascular/Peripheral Vascular: S1, S2, S3 noted with gallops. No murmurs or rubs. PMI displaced laterally at mitral area. Capillary refill less than 3 seconds. EKG-normal sinus rhythm with no ST elevations. Shadow Health Digital Clinical Experience Focused Exam Chest Pain Documentation

Respiratory: Breath sounds clear to auscultation. Unlabored breathing noted.. Fine crackles in right middle lobe and posterior left lower lobe.

Gastrointestinal: Symmetric, round, soft abdomen, no abnormalities. No abdominal bruits Normoactive bowel sounds. All areas are generally tympanic on percussion. No tenderness to both light and deep palpitation..

Musculoskeletal: 5/5 strength and Full ROM in both extremities.

Neurological: Alert and oriented x 4. Cranial Nerves grossly intact. DTR’s intact

Skin: no visible abnormalities in nails. No cyanosis, skin tenting, or lesion noted

Diagnostic Test/Labs:

EKG- Normal rate and rhythm. No ST elevation.

ASSESSMENT:

Angina Pectoris (Stable Angina): This particular kind of chest pain is brought on by an inadequate supply of blood to the heart. It is a sign that you may be suffering from coronary artery disease. People often use words like “squeezing,” “pressure,” “heaviness,” “tightness,” and “pain” to describe the sensation that they experience in their chests. There is a possibility that it may seem like a big weight is resting on the chest. It’s possible that your angina pectoris is a new discomfort that needs to be checked out by a medical professional, or it might be a reoccurring pain that goes away after you get treatment for it. It is not always easy to differentiate angina pectoris from other forms of chest pain, such as the discomfort caused by indigestion, despite the fact that angina pectoris is rather prevalent (Gillen & Goyal, 2021).

Congestive Heart Failure:  This is a condition that manifests itself when the muscle of the heart fails to pump blood as effectively as it should. When anything like this takes place, the body’s blood supply often reverses, and fluid may accumulate in the lungs, leading to a sensation of being unable to catch one’s breath. Certain cardiac disorders, such as restricted arteries in the heart or high blood pressure, can progressively leave the heart unable to fill and pump blood adequately because it will become too weak or stiff (Malike et al, 2021). Symptoms include things like exhaustion, shortness of breath, swelling legs, and a racing pulse.

Coronary Artery Disease: This is a condition that is brought on by a restriction in the blood flow via the coronary arteries, which is often brought on by atheromas. There are a number of clinical symptoms, some of which include silent ischemia, angina pectoris, acute coronary syndromes, and sudden cardiac death. The diagnosis is made based on the patient’s symptoms, as well as the results of an electrocardiogram, stress test, and sometimes, coronary angiography (Shahjehan & Bhutta, 2021).  Shadow Health Digital Clinical Experience Focused Exam Chest Pain Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

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:

1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations

Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdp, Flu, pneumonia, etc.

Significant Family History: Include history of parents, Grandparents, siblings, and children.

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: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

                Cardiovascular/Peripheral Vascular:

                Respiratory:

                Gastrointestinal:

                Musculoskeletal:

                Psychiatric:

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: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

              Cardiovascular/Peripheral Vascular: Always include the heart in your PE.

Respiratory: Always include this in your PE.

Gastrointestinal:

Musculoskeletal:

Neurological:

Skin:

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. Shadow Health Digital Clinical Experience Focused Exam Chest Pain Documentation