Focused Health History and Physical Assessment-Chest Pain.

It is important you strictly structure the paper in line with the submission parameters. Assignment Instructions: For this 4-5 page assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health. Particularly, you will complete a focused assessment on Brian, an adult who is complaining of chest pain. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment. Submission Parameters: For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations.Focused Health History and Physical Assessment-Chest Pain.

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The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s). Introduction (including purpose statement) Focus of the assessment Describe the focus of this particular assessment on the patient complaining of chest pain Subjective Component Describe the ROS, PMH, and other relevant data in this section. Focused Health History and Physical Assessment-Chest Pain.Objective Component Describe the physical examination findings including techniques of examination Documented evidence to support clinical reasoning Describe the list of differential diagnoses Plan of care Describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for each focused area of assessment. Conclusion References (use primary and/or reliable electronic sources) In regards to APA format, please use the following as a guide: Include a cover page and running head (this is not part of the 4-5 pages limit) Include transitions in your paper (i.e. headings or subheadings) Use in-text references throughout the paper Use double space, 12 point Times New Roman font Apply appropriate spelling, grammar, and organization Include a reference list (this is not part of the 4-5 pages limit) Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP).Focused Health History and Physical Assessment-Chest Pain.

Introduction

In this paper, the author discusses the assessment of a 58-year-old who had periodic chest pains. Patients presenting with chest pain without a trauma history comprise the majority of those who visit emergency rooms and primary care settings. It is possible to determine the etiology of chest pain from a patient’s history and the most vital part in describing the characteristics of pain is its relieving and aggravating factors. NPs must be able to systematically evaluate other aspects such as the characteristic of pain which is crucial for developing a list of the most probable causes, guides the physical exam, and choice of diagnostic tests.Focused Health History and Physical Assessment-Chest Pain.

The focus of the Assessment

This assessment focuses on a 58-year-old patient who had a complaint of constant chest pain. The author discusses the history taking, physical examination, and assessment based on the complaint of chest pains to make an accurate diagnosis and care plan. In the clinical history, the author focuses on the characteristics of chest pain and assesses it further using the PRST pain assessment tool, the past medical history (history of pulmonary or vascular disease, allergies, and underlying chronic illnesses), social history(use of illicit drugs, tobacco, and alcohol), and family history(familial history of chronic cardiovascular illnesses). The physical exam focuses on the presence of carotid upstroke, cyanosis, signs of peripheral edema, lung sounds, pulses, use of accessory muscles, and distress.Focused Health History and Physical Assessment-Chest Pain.

Subjective Component

CC-chest pain

HPI-the patient is a 58-year-old day complaining of chest pain that started early during the month. He describes the pain as squeezing pressure, rates its severity as 5/10, and explains that it was localized at the mid-sternum. Apart from being constant, he explains that it increased in severity. He associated the pain with left shoulder pressure and onset nausea but denied emesis. The pain lasts for several minutes, is aggravated by physical activity, and is relieved by resting. This month, he reports that he experienced the pains three times.Focused Health History and Physical Assessment-Chest Pain.

Medications: Metoprolol (Lopressor) 100mg PO OD, atorvastatin (Lipitor) 20 mg PO OD, Omega-3 Fish Oil 1200 mg PO, ibuprofen 800mg BID.

Allergies: medications; codeine-nausea and vomiting, environment-none, food-none.

Past Medical and Surgical History: the patient is up to date with all immunizations. Recently, he received influenza and Tdap.  He was also diagnosed with hyperlipidemia and stage II hypertension one year ago but has never been diagnosed with angina or have a significant surgical history. He reported no significant surgical history or diagnosis with angina. Mr. Foster has no history of DM or has previously been managed for CP. He does not monitor his BP at home and no knowledge about his typical BP.  His last stress test and EKG were three months ago. His last visit to a PCP was three months ago and he did see a cardiologist.

Social History: he reported no presence or history of illicit or tobacco use, consumes between 2-3 beers over the weekends, and currently, he states that he has a low lifestyle and job stress. Mr. Foster denies performing regular physical activity since his bike was stolen. For most of his breakfasts, he takes a breakfast shake or granola bar, for lunch, he takes Italian salad or sub, and grilled meat with vegetables for dinner. Over the weekend, he emphasizes taking big breakfasts.  However, he rarely monitors his intake of drinks and salt since he consumes two cups of coffee daily, 1L   of water, and a whole pot of coffee on Sundays. However, he does not consume soda.Focused Health History and Physical Assessment-Chest Pain.

Family History: The patient’s father is deceased (at 75 years) due to colon cancer. He also had hyperlipidemia, hypertension, and obesity. His mother (80 years) was diagnosed with type 2 DM and hypertension, the maternal grandfather died of MI    but there is no familial history of stroke or PE. His brother (24) and sister (52) are deceased to an MVA, and hypertension/type 2DM related complications respectively. Mr. Foster’s maternal grandmother died at 65 secondary to breast CA related complications. Maternal grandfather deceased at 54 (MI), paternal grandmother deceased at 78 (PNA), paternal grandfather deceased at 85. Mr. Foster’s son alive and healthy, presently 26 years old, his daughter (19years) is also alive but was diagnosed with asthma.Focused Health History and Physical Assessment-Chest Pain.

Review of Systems (ROS)

Constitutional: denies fatigue, has gained   15-20 lbs   weight   in the last couple of years due to inactivity, denies night sweats, fever, and chills

HEENT: denies vision changes, denies sore throat, denies difficulty in swallowing

Skin: denies cyanosis and pallor

Respiratory: denies cough, dyspnea, and pain on inspiration

Neurological: denies lightheadedness, denies dizziness, numbness, tingling in hands and feet, gets a HA once in a blue moon

Cardiovascular: has constant chest pains, intolerant to exercise thus cannot engage in physical activity as it aggravates the chest pain, denies palpitations, denies history of cyanosis and blood clots but reports on easy bleeding/bruising.Focused Health History and Physical Assessment-Chest Pain.

Objective Component

Vital signs: BP 146/88mmHg, PR-104, RR-19, O₂ Sat 98% R/A, Temp 36.27⁰C, pain 5/10

General Exam: Alert and oriented adult who appears uncomfortable lying supine on the hospital bed. He appears to be mildly diaphoretic and pale, he has an increased respiratory rate and

Skin: Skin is intact, warm, dry and with slight diaphoresis and pallor, no purulence, redness, or induration noted.

Respiratory: Unlabored and quiet breathing, on auscultation of the upper lobes of the lungs and RML, the patient’s breath sounds are clear. The posterior bases of the lungs have fine crackles/rakes

Neurological: Patient is alert and oriented in time place and person (AOX3), moves all the extremities, and follows commands. Focused Health History and Physical Assessment-Chest Pain.

Cardiovascular: S1 and S2 heard with no rubs or murmurs. The femoral, brachial, and radial pulses have no thrills 2+, no thrill 1+ on the pulses of the tibia, popliteal, and dorsalis pedis, the capillary refill-less than three seconds on all four extremities, and the JVP is 3cm. The left carotid pulse has a bruit 2+and the right carotid pulse 3+. There is lateral displacement of the PMI and there is an S3 in the mitral area. No edema of the lower extremities, focal erythema or induration, and varicosities.

Gastrointestinal/Abdomen: round, soft and not distended, normoactive bowel sounds, no bruits, no hepatosplenomegaly, non-palpable bilateral kidneys and spleen

Documented Evidence to Support Clinical Reasoning

• Coronary Artery Disease (CAD) with a stable angina-the patient presented with a complaint of constant chest pain which worsened with activity and was relieved with rest. He associated the pain with a feeling of ‘pressure’ on the left shoulder. He had an underlying diagnosis of hyperlipidemia, gender (male), a history of physical inactivity, a familial history of heart diseases, hypertension, and a sedentary lifestyle which are potential risk factors of CAD (Fanaroff et al, 2015).
• Congestive heart failure-Mr. foster had a history of physical inactivity despite being diagnosed with hypertension and hyperlipidemia which are potential risk factors of heart failure. Besides, he had an elevated heart rate and the PMI was laterally displaced indicating cardiomegaly (Kurmani & Squire, 2017).Focused Health History and Physical Assessment-Chest Pain.

Plan of Care

Order for the following additional diagnostic tests

• Cardiac enzymes-to assess the degree of damage caused by a heart attack to heart muscles.
• Blood electrolytes-To assess the patient’s  kidney function
• CBC, BNP, HgbA1C- the BNP test will help to determine whether Mr. Foster has underlying heart failure and the HgbA1C will help to determine his risk of DM.Focused Health History and Physical Assessment-Chest Pain.
• CMP, Lipid profile, and Liver Function test

Pharmacologic Intervention

• Diuretic therapy (furosemide) 20mg PO OD
• ACE inhibitors (Enalapril) 5mg PO OD.
• Nitroglycerin 0.3mg PRN

Non-pharmacological

Referral- it will be appropriate to immediately refer Mr. Foster to a cardiologist and a vascular surgeon for further evaluation and management who will perform tests on exercise stress, order for an echocardiogram, and a bilateral carotid Doppler (Smith et al, 2015). To have his carotid examined further by a vascular surgeon. Focused Health History and Physical Assessment-Chest Pain.

Lifestyle modification-it will be important to educate Mr. Foster on lifestyle modifications with regards to physical activity and nutrition. Patients diagnosed with hypertension must maintain a DASH diet for effective blood pressure management (Kim & Andrade, 2016). This will require the intervention of a dietician. Focused Health History and Physical Assessment-Chest Pain.

Follow-up- the author will ask Mr. Foster to seek immediate assistance the pain worsens or is associated with symptoms of nausea, dizziness, and SOB and to return to the clinic immediately after five days to assess for progress. Focused Health History and Physical Assessment-Chest Pain.

Conclusion

Patients presenting with the complaint of chest pain that has a non-traumatic origin are the most common in emergency rooms and primary care settings. This health assessment focused on a 58-year-old who had complaints of constant chest pain. The physical examination revealed that he had an elevated pulse rate and respiratory rate and there was an audible S4 on auscultation on the heart. Based on the findings from the subjective and objective data, the most likely diagnosis is coronary artery disease with stable angina. Focused Health History and Physical Assessment-Chest Pain.