![MS: Knee: Full active range of motion in all joints of the upper
and lower ext. No evidence of swelling or deformity.
Male Genitalia: deferred
Assessment Patient reports chest discomfort and shortness of
breath with exertion and has history of hypertension and high
cholesterol. The most likely diagnoses are as follows:
Differentials (with rationale for each): 1. Stable Angina:
Evidence by chest discomfort and Shortness of breath on
exertion.
2. Pulmonary embolism: Dyspnea is the most common symptom
of acute pulmonary embolus
3. GERD: Esophageal reflux typically presents as an epigastric
or retrosternal burning pain, with radiation toward the throat.
Diagnosis: Stable Angina
Plan
Diagnostics: 1. Resting EKG: May reveal ST-T changes
suggestive of ischemia or Q waves indicative of prior
infarction.
2. Stress Test
3. Coronary Angiogram
Treatment: The treatment goals of patients with Stable Angina
are to:
· Reduce premature cardiovascular death
· Prevent complications of Angina (i.e., nonfatal myocardial
infarction [MI] and heart failure) that lead to impaired
functional status
· Maintain or restore level of activity and quality of life](https://image.slidesharecdn.com/clinicaldocumentationtemplatestudentdeepaksharma-230111174235-09a20146/85/Clinical-Documentation-TemplateStudent-Deepak-Sharma-docx-5-320.jpg)
Clinical Documentation TemplateStudent Deepak Sharma .docx
- 1. Clinical Documentation Template Student: Deepak Sharma Site: Elgin Medical Ctr Client’s Initials: MS Age : 64 Gender : Male Date: 04/07/2019 Subjective Chief Complaint: 64 year old Hispanic male present to the clinic with chest discomfort. HPI: Mr. JG. is a 64-year old male with a history of HTN and dyslipidemia present to the clinic with chest discomfort for past two month. Patient stated that chest discomfort is in the middle of his chest and it feels like a burning sensation along with tingling. Patient rated his pain 5 out of 10. Patient also stated that mostly happen when I am doing activity like climbing stairs however sometime it does happen when I am just watching TV. Patient denies any episodes of felling dizzy or passing out. Patient denied radiation of the pain to neck or jaw. He took Advil and it is not doing anything. Patient is non-compliance with his cholesterol medication. ROS: General: has slowly gain weight over last ten years, denies weakness, , fevers, memory changes, nervousness, anxiety,depression, suicide. Skin: no rash, lumps, sores, itching, dryness, color change, change in hair/nails, bruising or bleeding, excessive sweating, heat or cold intolerance. Head: Denies headache, head injury, dizziness. Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred
- 2. vision, or blindness. Ears: no hearing change, tinnitus, infection, discharge. Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis. Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago. Neck: No lumps, swollen glands, goiter, pain, or neck stiffness. Neuro: No syncope, seizures, weakness, paralysis, numbness, tremors, or involuntary movements. Pulmonary: Dyspnea with activity, negative hemoptysis, wheezing, pleuritic pain Neuro: No headache dizziness, focal numbness/weakness, nausea, vomiting. Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots, abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness, pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather. Swelling with redness or tenderness. MS: no muscle, joint pain, or joint stiffness, positive for chest pain GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain, belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food intolerance, indigestion, nausea, vomiting, early fullness, odynophagia. GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria, nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids. Past Medical History: Hypertension, dyslipidemia
- 3. Surgeries: none Hospitalizations: None Allergies: NKA Food, drug, environmental: NKA Medications: Lisinopril 5 mg daily Hydrochlorothiazide 25 mg daily Family History: His mother died at 72 and his father died at 88, both due to complications from HTN and CHF. He denies any known family history of autoimmune. Social History: Drinks alcohol socially and has never used illicit substances. He categorizes his diet as good with a variety of foods (lean mean, fruit, vegetables, grains) but admits to eating mostly meat (chicken and red meat) with very few vegetable and grains up until about 2 years ago. He does not exercise on regular basis. Objective Vital Signs: BP: 136/80 Pulse: 86 RR : 16 Pain : 8/10 Height: 5’ 6” Weight : 220 lbs BMI: 35.5 SpO2: 98% RA Labs: None General Survey: 64 year old male sitting up in a chair in no apparent distress. Patient is cooperative, alert and oriented x 4. Speech is fluid and appropriate. Skin is warm and moist with adequate skin turgor and full hair distribution on scalp, trunk and extremities. No pallor, jaundice, cyanosis or clubbing. Capillary refill < 2 seconds on nails of hands and feet.
- 4. Exam : Head: hair normal texture and distribution, no lumps/bumps/lesions noted to scalp. Scalp/skull non-tender with palpation. Skull normocephalic/atraumatic. Eyes: no drainage noted, PERRLA, Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat. . Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddned bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline. Throat: oral mucosa pink and moist, tongue mobile without lesions, tonsils absent. Neck: non-tender cervical area, no lymph nodes palpable. Non- enlarged thyroid palpated. Trachea midline. Neuro: denies any numbness, .Alert and oriented x 4, CN I – not tested, II-XII intact. Deep tendon reflexes 2+ Brachioradialis, bicep, triceps, supinator, knee, and ankle with plantar reflexes down-going. No clonus. Muscle strength 5/5. Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs resonant. Breath sounds vesicular: no crackles or wheezes. No egophony or whispered pectoriloquy. Diaphragm descends 4cm bilat. Cardio: JVP is 3cm. above the sternal angle with the head of bed elevated to 30 degrees. Carotid upstrokes are brisk without bruits. Temporal arteries have normal pulsation without tenderness. The point of maximal impulse is taping, 8 cm lateral to the mid-sternal line in the 5th intercostal space. Crisp S1 S2 without clicks or murmurs. Extremities are warm and without edema. No variscosities or stasis changes. Calves are supple and non-tender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ and symmetric. Ca refill <2 secs. Abdomen: soft flat, non-tender and non-distended. Normoactive bowel sounds. No palpable masses or hepatosplenomegaly. Liver span is 7cm in the right midclavicular line. Edge not palpable. Kidneys not felt. No CVA tenderness.
- 5. MS: Knee: Full active range of motion in all joints of the upper and lower ext. No evidence of swelling or deformity. Male Genitalia: deferred Assessment Patient reports chest discomfort and shortness of breath with exertion and has history of hypertension and high cholesterol. The most likely diagnoses are as follows: Differentials (with rationale for each): 1. Stable Angina: Evidence by chest discomfort and Shortness of breath on exertion. 2. Pulmonary embolism: Dyspnea is the most common symptom of acute pulmonary embolus 3. GERD: Esophageal reflux typically presents as an epigastric or retrosternal burning pain, with radiation toward the throat. Diagnosis: Stable Angina Plan Diagnostics: 1. Resting EKG: May reveal ST-T changes suggestive of ischemia or Q waves indicative of prior infarction. 2. Stress Test 3. Coronary Angiogram Treatment: The treatment goals of patients with Stable Angina are to: · Reduce premature cardiovascular death · Prevent complications of Angina (i.e., nonfatal myocardial infarction [MI] and heart failure) that lead to impaired functional status · Maintain or restore level of activity and quality of life
- 6. · Completely, or nearly completely, eliminate anginal symptoms Tx line Treatment Ist Life style modification- Patient education includes ongoing assessments and recommendations to help patients achieve weight management, increased physical activity, dietary modifications, lipid goals. Plus Anti-platelet Therapy- All patients should be started on aspirin and this should be continued indefinitely. For patients with a contraindication to aspirin therapy, it is reasonable to use clopidogrel Asprin 75 mg to 162 mg daily OR Clopidrogel 75 mg daily Adjunct Antianginal Therapy- Carvedilol 6.25 to 25 mg orally twice daily Adjunct Atorvastatin - moderate intensity: 10-20 mg orally once daily; high intensity: 40-80 mg orally once daily For Acute Anginal Symptoms : nitroglycerine 0.4 mg sublinguial. Coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) is recommended to relieve anginal symptoms in patients with continued unacceptable angina despite maximal medical therapy Follow up: With Cardiologist in one week.
- 7. History and Physical Informant: Patient, who is AOX3 and old chart. Chief Complaint: This is 64 year old Hispanic male with PMH of hypertension and dyslipidemia present to the clinic with chest discomfort. Patient stated that chest discomfort is in the middle of his chest and it feels like a burning sensation along with tingling. History of Present Illness: Mr. JG. is a 64-year old male with a history of HTN and dyslipidemia present to the clinic with chest discomfort for past two month. Patient stated that chest discomfort is in the middle of his chest and it feels like a burning sensation along with tingling. Patient rated his pain 5 out of 10. Patient also stated that mostly happen when I am doing activity like climbing stairs however sometime it does happen when I am just watching TV. Patient denies any episodes of felling dizzy or passing out. Patient denied radiation of the pain to neck or jaw. He took Advil and it is not doing anything. Patient is non-compliance with his cholesterol medication. Current Regimen: Lisinopril 5 mg daily Hydrochlorothiazide 25 mg daily Past Health General: Hernia repain 2002, Last mammogram 2004, colonoscopy 1997, relatively good health otherwise. ROS: General: has slowly gain weight over last ten years, denies weakness, , fevers, memory changes, nervousness, anxiety,depression, suicide. Skin: no rash, lumps, sores, itching, dryness, color change, change in hair/nails, bruising or bleeding, excessive sweating, heat or cold intolerance. Head: Denies headache, head injury, dizziness.
- 8. Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness. Ears: no hearing change, tinnitus, infection, discharge. Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis. Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago. Neck: No lumps, swollen glands, goiter, pain, or neck stiffness. Neuro: No syncope, seizures, weakness, paralysis, numbness, tremors, or involuntary movements. Pulmonary: Dyspnea with activity, negative hemoptysis, wheezing, pleuritic pain Neuro: No headache dizziness, focal numbness/weakness, nausea, vomiting. Cardiac : See HPI. MS: no muscle, joint pain, or joint stiffness, positive for chest pain GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain, belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food intolerance, indigestion, nausea, vomiting, early fullness, odynophagia. GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria, nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids. Social History: Patient has never smoked. She drinks alcohol rarely, does not use recreational drugs and is monogamous in a married relationship for many years. She has two grown children and works as a secretary. She does not exercise on a regular basis. Dietary history was not detailed but she did admit to eating "quite a bit of fast food.
- 9. Family History: Her father died of a heart attack at age 58. Mother is alive and in relatively good health. One sister has Hypertension & adult-type diabetes. Physical Exam 1. Vital Signs: temperature 98.2 Pulse 94 regular with occasional extra beat, respiration 20, blood pressure 158/92 2. Generally a well developed, slightly obese, . 3. HEENT: Eyes: extraocular motions full, gross visual fields full to confrontation, conjunctiva clear. sclerae non-icteric, pulpils equal round and reactive to light and accomodation, fundi not well visualized due to possible presence of cataracts. Ears: Hearing very poor bilaterally. Tympanic membrane landmarks well visualized. Nose: No discharge, no obstruction, septum not deviated. Mouth: Complete set of upper and lower dentures. Pharynx not injected, no exudates. Uvula moves up in midline. Normal gag reflex. 4. Neck: jugular venous pressure 8cm, thyroid not palpable. No masses. 5. Nodes: No adenopathy 6. Chest: Breasts: atrophic and symmetric, non-tender, no masses or discharges. Lungs: diminished lung sound, No dullness to percussion. Diaphragm moves well with respiration. No rhonchi, wheezes or rubs. 7. Heart: PMI at the 6th ICS, 1 cm lateral to MCL. No heaves or thrills. Regular rhythm with occasional extra beat. Normal S1, S2 narrowly split; Pulses are notable for sharp carotid upstrokes. Pulses: Carotid brachial radial femoral +2 8. Spine: mild kyphosis, mobile, nontender, no costovertebral tenderness 9. Abdomen: soft, flat, bowel sounds present, no bruits. Nontender to palpation. Liver edge, spleen, kidney not felt. No masses. Liver span 10cm by percussion. 10. Extremities: skin warm and smooth except for chronic venous stasis changes in both legs. 1+ edema to the knees, non- pitting and very tender to palpation. No clubbing nor cyanosis.
- 10. 11.Neurological: Awake, alert and fully oriented. Cranial nerves III-XII intact except for decreased hearing. Motor: Strength not tested, patient moves all extremities. Sensory: Grossly normal to touch and pin prick. Cerebellar: no tremor nor dysmetria. Reflexes symmetrical 1+ through out, no Babinski sign. 12. Pelvic: deferred until patient more stable. 13. Rectal: Prominent external hemorrhoid, No masses felt. Stool brown, negative for blood Labs: Troponin negative times 2, CBC and CMP WNL. CXR portable AP, probable cardiomegaly, mild PVC Impression Because patiet's discomfort has been present for two months, seems to follow a relatively predictable pattern, and has not worsened in severity, frequency, or occurred at rest, her chest pain, if angina, would be characterized as stable angina. Plan: 1. Resting EKG 2. Stress Test 3. Coronary Angiogram