Brian foster shadow health transcript

Brian foster shadow health transcript Assignment

Focused Exam: Chest Pain Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313481/) (/site_notice_dismissals?from_flash=true&site_noticBecome a paid student tester for Shadow Health! Click here for more information (https://www.surveymonkey.com/r/TN9CMB5) (/site_notice_dismissals?from_flash=true&site_noticShadow Health will be performing planned maintenance this Friday, from 7:00am until 7:30am Eastern. During this time assignment attempts will be disabled. Thank you for helping us to improve your Shadow Health experience!

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Brain is a 58 you Caucasian Male who presents with C/o chest pain in the middle of his chest over his heart, 3 times this month. His pain is 5/10 when the pain arises, no chest pain currently. Chest pain does not radiate to his arm, shoulder or neck. Aggravated chest pain when walking up the steps, and is relieved when he rests. Denies any heartburn, difficult breathing. No change in appetite but mentioned he gained some weight when his bike was stolen. Rare exercise at this moment, desires clearance for exercise since the onset of his chest pain. Never been seen for chest pain, and has not taken anything for chest pain. Medical history: HTN on Lopressor 100 mg/daily x1 year Hyperlipidemia on Lipitor 20 mg daily x1 year Omega 3 daily No surgical history Family Medical hx: Father: htn/hyperlipidemia, obesity, died of colon cancer @ 75yo MGF: heart attack died @ 54 yo Sister: HTN and Diabetes type 2 Social hx: beer 3 drinks in a weekend denies tobacco or drug use

 

Pt. reports “I have been having some troubling chest pain in my chest now and then for the past month.” Experiencing periodic c pain with exertion such as yard work as well as with overeating. Points to midsternum as location. Describes pain as “tight and uncomfortable.” Denies radiation. Pain lasts for “a few” minutes goes away when he rests. Most recent episode was three days a after eating a large restaurant dinner. States “It has never gotten ‘really bad’” so didn’t think it was an emergency, but is concerned after three episodes in one month and wants his heart checked o Reports mild cramping in legs with activity. Denies shortness of breath, indigestion, heartburn. Denies chest pain at this time. Your Results Lab Pass (/assignment_attempts/6701636/lab_pass.pd

Get Help with Brian foster shadow health transcript

Overview

Transcript

 

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Vitals Document: Provider Notes

https://aspen.shadowhealth.com/assignments/313481/

https://aspen.shadowhealth.com/site_notice_dismissals?from_flash=true&site_notice_id=419

https://www.surveymonkey.com/r/TN9CMB5

https://aspen.shadowhealth.com/site_notice_dismissals?from_flash=true&site_notice_id=418

https://aspen.shadowhealth.com/assignment_attempts/6701636/lab_pass.pdf

Student Documentation Model Documentation

 

Objective

 

Brian is a 58 year old Caucasian male appears to be well-groomed, is pleasant and answers questions clearly and appropriately. He maintains eye contact throughout the exam. He appears in no distress VSS: Bp 146/90 Skin warm to touch, dry, pink and intact. no tenting Heart: S1, s2, s3 and S4 with murmur Carotid pulse: positive Thrill, +3 on right: PMI: displaced laterally, brisk and tapping, <3cm Breath sounds: clear in upper lobes, posterior lower lobes with crackles bilaterally. GI: no tenderness, no masses, guarding or distension. BS present at all quads, WNL Liver is palpable and nontender: spleen and kidneys are not palpable Extremities: No edema, Brachial and radial pulse neg for thrill at 2+ popliteal, tibal and dorsalis pedis pulse diminished at 1+. capillary refill less than 3 seconds on extremities. EKG: Regular sinus rhythm. No ST changes

 

  • General Survey: 58 year old male is alert and oriented, with clea speech and in no acute distress.
  • Cardiac: S1, S2, without murmurs or rubs. PMI displaced latera S3 noted at mitral area

. • Peripheral Vascular: Right side carotid bruit. JVP 3cm above ste angle. Right carotid pulse with thrill, 3+. Left carotid pulse withou thrill, 2+. Brachial, radial, femoral pulses without thrill, 2+. Poplite tibial, and dorsalis pedis pulses without thrill, 1+. Cap refill less t 3 seconds – 4 extremities.

  • Respiratory: Breathing is quiet and unlabored. Breath sounds a clear to auscultation in upper lobes and RML. Fine crackles/rales posterior bases of L/R lungs.
  • Gastrointestinal: Round, soft, non-tender with normoactive bow sounds in 4 quadrants; no abdominal bruits. No tenderness to lig or deep palpation. Tympanic throughout. Liver is 7 cm at the MC and 1 cm below the right costal margin. Spleen and bilateral kidn are not palpable.
  • Neuro: Alert and oriented x 3, follows commands, moves all extremities.
  • Skin: Warm, dry, pink, and intact. No tenting.
  • EKG (interpretation): Regular sinus rhythm. No ST changes.

 

Assessment

 

Coronary Artery disease Stable angina Carotid disease pericarditis Aortic aneurysm r/o GERD R/O Sarcodosis

 

Based on the abnormal findings during cardiovascular and respiratory auscultation, my differentials include coronary artery disease with stable angina; congestive heart failure; carotid disea aortic aneurysm; pericarditis; or GERD.

 

Plan

 

Blood work for cardiac enzyme, electrolytes, CBC, Lipid profile, liver function test, cxr, 12 lead EKG Consult with cardiologist Echocardiogram Exercise stress test Dopplers for carotid Patient should be tested with results on labs at the least, and not discharged home. Baby Asa upon arrival Ntiroglycerin if chest pain is present again Warning signs of when to seek medical help like another onset of chest pain, SOB, shoulder or arm pain

 

Mr. Foster should receive a 12-lead ECG, chest x-ray, and lab workup (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1 lipid profile, and liver function tests) to confirm a diagnosis. He should be referred for an echocardiogram, exercise stress test, a carotid dopplers as well as a consult with a vascular surgeon for carotid evaluation. Mr. Foster should be prescribed diltiazem and diuretic in addition to his daily Lopressor and Lipitor. If needed, an ACE inhibitor to manage his hypertension and PRN nitroglyce for chest pain that does not subside with rest.

Place Order Now

Quality Assignments Help Website

Cost of your order

Pages

Why Choose Us

Top Quality and Well-Researched Papers

We ensure that all your instructions are followed to the letter. You are able to choose the level of interest; professional, college, or high school. We will assign a writer who will cover all your specifications.

Professional and Experienced Academic Writers

We have a team of well trained and experiences assignment writers who are PhD and master’s holders. Our writers are can handle more than 91 disciplines.

Free Unlimited Revisions

If your assignment is not covered to your expectation, you can send your order for revision. The order should be submitted before 10 days elapses for review You can contact our support team or login to your personal account to submit your request.

100% Money-Back-Guarantee

We ensure on-time delivery of your papers. For clarification purpose, we may contact you regarding deadline extension. In case you cannot provide us with more time, we guarantee a 100% refund.

Originality & Confidentiality

We use professional tools to ensure all assignment help documents you receive are free of plagiarism. Our editors ensure optimum review of all quotations in the text. We also ensure confidentiality in our service delivery.

24/7 Customer Support

Our team of experts is available 24/7 to ensure that you are provided with the top customer experience. Any time you need assignment help, you can reach us and get the best experience with ours services.

Our Services

You don’t have to struggle with your papers. You need ample sleep; our writers will cover you. We provide writing services in all disciplines.

Essays

Essay Writing Services

No matter what kind of academic paper you need and how urgent you need it, you are welcome to choose your academic level and the type of your paper at an affordable price. We take care of all your paper needs and give a 24/7 customer care support system.

Admissions

Admission and Business Papers

An admission essay is an essay or other written statement by a candidate, often a potential student enrolling in a college, university, or graduate school. You can be rest assurred that through our service we will write the best admission essay for you.

Editing

Editing and Proofreading

Our academic writers and editors make the necessary changes to your paper so that it is polished. We also format your document by correctly quoting the sources and creating reference lists in the formats APA, Harvard, MLA, Chicago / Turabian.

Coursework

Revision Support

If you think your paper could be improved, you can request a review. In this case, your paper will be checked by the writer or assigned to an editor. You can use this option as many times as you see fit. This is free because we want you to be completely satisfied with the service offered.