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NURS 6512 Week 7 Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

Name: Mr. J.M. Age: 38 years Sex: Male
SUBJECTIVE DATA:
Chief Complaint (CC): “I have sporadic chest pain”
History of Present Illness (HPI): Mr. J.M. is a 38-year-old African American male who
presented to the emergency department with complaints of sporadic chest pain for the last one
month. The pain is usually centrally located and radiates to the left arm. He has experienced 3
episodes since the last month with each episode lasting several minutes. Currently, the pain is at
0 on a scale of zero to 10 although it is generally at 5 at its worst. The pain is characteristically
uncomfortable and tight. It is aggravated by activities such as climbing stairs and yardwork while
brief episodes of rest relieve the pain. He has not taken any medications for the pain.
Medications: Reports taking Lopressor 100mg PO once daily for hypertension and Lipitor 20mg
PO once daily for hyperlipidemia as well as fish oil 1000mg PO twice daily.
Allergies: None
Past Medical History (PMH): Reports hypertension and hypercholesterolemia. No previous
hospitalizations or blood transfusions. Denies prior chest pain treatment. Poor blood pressure

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monitoring both at home. Denies regular blood pressure checks at the pharmacy and drug store.
Reports a recent EKG test that was normal. His last visit to a healthcare provider was three
months ago.
Past Surgical History (PSH): No previous surgeries.
Sexual/Reproductive History: Heterosexual.
Personal/Social History: Has lived a relatively stress-free lifestyle. Regular water intake of
about a liter per day. Drinks 2 cups of coffee daily. Denies routine regular physical activity and
his last regular exercise was 2 years ago. Reports moderate alcohol consumption of about 2 to 3
drinks per week mostly on weekends but no tobacco or illicit drug use. His typical breakfast is a
granola bar and instant breakfast shake, lunch turkey sub, and his dinner is typically grilled meat
alongside vegetables.
Immunization History: All immunization up to date. The last COVID-19 vaccine was February
this year, the last Tdap was May 2022 and the last influenza was January 2022.
Significant Family History: His mother is 65 years old and hypertensive while the father is 70
years old and obese. The grandmother died at 77 years due to a heart attack while the grandfather
is 85 but suffered a stroke at 80 years. He has two daughters all alive and well.

Review of Systems:
General: Denies fever, changes in weight, chills, fatigue, night sweats, and palpitations.
Cardiovascular/Peripheral Vascular: No edema, easy bruising, angina, or easy
bleeding.

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Respiratory: No difficulty in bleeding, sputum, cough, or shortness of breath.
Gastrointestinal: Denies alteration in bowel habits, abdominal pain and nausea, and
vomiting
Musculoskeletal: No back pains, joint pains, and muscle weakness.
Psychiatric: No anxiety, depression, delusions, or hallucinations

OBJECTIVE DATA:
Physical Exam:
Vital signs: Temperature- 98.5 F, pulse 80 beats per min, respiratory rate- 19 breaths per
minute, blood pressure- 132/86 mmHg, saturation- 92% on room air, height 70. 86 inches,
weight 251 lbs. BMI- 29.

General: A young African American male, well kempt and groomed, and appropriate for
his stated age. Not in any obvious distress, good body built and well hydrated. No pallor,
finger clubbing, splinter hemorrhages, jaundice, cyanosis, lymphadenopathy, or
peripheral edema.
Cardiovascular/Peripheral Vascular: Nondistended neck veins (JVP less than 4cm
above sternal angle), right carotid pulse 3+ with a thrill and bruit, left carotid pulse 2+ with no
thrill or bruit, right and left brachial and radial arteries pulses 2+ with no thrills, right and left
femoral arteries pulses 2+ with no thrills and bruits, right and left popliteal arteries pulses 1+
with no thrills, right and left tibial and dorsalis pedis pulses 1+ with no thrills, no renal, iliac and

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abdominal aorta bruits, and capillary refill is less than 3 seconds in all the digits. Precordium is
brisk and tapping. The point of maximal impulse is displaced laterally and less than 3 cm, with a
heave but no thrill. S1, S2, and S3 were heard with gallops, no murmurs.
Respiratory: Symmetric chest, moves with respiration with no obvious scars or masses
on inspection. the trachea is central, with equal chest expansion, no tenderness or palpable
masses, and equal tactile fremitus on palpation. Resonant on percussion. Good air entry and
vesicular breath sounds in all lung zones, and no wheezes or rhonchi on auscultation.
Gastrointestinal: Nondistended, moves with respiration, symmetric, normal contour and
fullness, umbilicus everted and no visible distended veins, striae, or scars. No tenderness or
palpable masses on light and deep palpation. The liver is palpable 2 cm below the right costal
margin. Liver span 8 cm. Spleen and both kidneys are impalpable. Tympanic on percussion, no
shifting dullness or fluid thrill. No friction rubs over the liver and spleen.
Musculoskeletal: Normal muscle bulk, power of 5/5 in all muscle groups, normal
reflexes, and range of movement across all joints.
Neurological: GCS 15/15, oriented to time place, and person, all cranial nerves and
sensation intact, no neurological deficits noted, good bladder and bowel function.
Skin: No rashes, darkening, tenting, or nail changes.
Diagnostic Test/Labs: An EKG was done which revealed a sinus rhythm with no ST changes.
Other critical tests include cardiac biomarkers particularly, troponin T/I, CK-MB, and myoglobin
to exclude myocardial injury (Harskamp et al., 2019). Lipid profile and random blood sugar are
required to check the level of lipid control and exclude diabetes mellitus respectively.
Additionally, LDH to assess for cell necrosis, BNP to exclude concurrent heart failure, and

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inflammatory markers especially CRP for prognostication. Similarly, complete blood count with
differential, urea creatinine, and electrolytes as well as liver function tests are required as a
baseline for medication. Imaging tests include a transthoracic echocardiogram to assess left
ventricular function, detect any wall motion abnormalities and identify any complications
(Harskamp et al., 2019). Finally, a cardiac CT with IV contrast may be required to rule out
differentials such as pulmonary embolism and aortic dissection.

ASSESSMENT:
Mr. J.M. is a 38-year-old African American male, known patient with hyperlipidemia and
hypertension who presents with complaints of sporadic centrally located chest pain that radiates
to the left arm. The pain is usually aggravated by exertion but relieved by rest with a history of
physical inactivity. On examination, the right carotid artery pulse is increased with a bruit and
thrill, the apex is displaced laterally, and S1, S2, and S3 are heard with gallops but no murmurs.
Main Diagnosis- The primary diagnosis is stable angina. Mr. J.M. presents with retrosternal
chest pain that is tight and uncomfortable and that radiates to the left arm. This is characteristic
of angina. However, these symptoms are worsened by exertion but relieved by rest which is a
distinct feature of stable angina (Rousan & Thadani, 2019). According to Rousan and Thadani
(2019), atherosclerosis is the most common etiology of this condition. Mr. J.M. has classic risk
factors for atherosclerosis including arterial hypertension, hyperlipidemia, alcohol consumption,
and overweight as well as a family history of cardiovascular events.
Differential diagnosis

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Non-ST segmented elevated myocardial infarction- Myocardial infarction refers to an acute
myocardial injury caused ischemia that results in tissue necrosis. This condition also presents
with a retrosternal chest pain that dull and tight, precipitated by exertion and radiates to the left
arm, shoulder, neck or jaw. Myocardial infarction may also be precipitated by an atherosclerotic
event. However, lack of ST changes on EKG suggests NSTEMI (Cohen & Visveswaran, 2020).
Hypertension and hyperlipidemia- Mr. J.M. has previous history of hypertension on metoprolol
and hyperlipidemia on Lipitor. Furthermore, lateral displacement of the apex beat as well as a
heave suggest left ventricular hypertrophy which is usually a consequence of arterial
hypertension (Oparil et al., 2018).

© 2021 Walden University

References

Cohen, M., & Visveswaran, G. (2020). Defining and managing patients with non-ST-elevation
myocardial infarction: Sorting through type 1 vs other types. Clinical Cardiology, 43(3),
242–250. https://doi.org/10.1002/clc.23308
Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W. A. M., & van Weert, H. C. P.
M. (2019). Chest pain in general practice: a systematic review of prediction rules. BMJ
Open, 9(2), e027081. https://doi.org/10.1136/bmjopen-2018-027081
Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F.,
Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018).
Hypertension. Nature Reviews. Disease Primers, 4(1), 18014.
https://doi.org/10.1038/nrdp.2018.14
Rousan, T. A., & Thadani, U. (2019). Stable angina medical therapy management guidelines: A
critical review of guidelines from the European Society of Cardiology and National
Institute for Health and Care Excellence. European Cardiology, 14(1), 18–22.
https://doi.org/10.15420/ecr.2018.26.1

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