Brian Foster Chest Pain Shadow Health Assessment

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Brian Foster Chest Pain Shadow Health Assessment

Introduction and Pre-brief

This assignment provides the opportunity to conduct a focused exam on Brian Foster, who presents with recent episodes of chest pain in a non-emergency setting. Interview Mr. Foster and be sure to thoroughly assess the cardiovascular system as well as related body systems in order to compile a list of differential diagnoses. This case study offers you the opportunity to evaluate Mr. Foster’s personal and family history with heart disease and identify lifestyle risk factors. During the physical examination, thoroughly examine the cardiovascular system and carefully evaluate and document the patient’s heart sounds.

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Tips and Tricks

The sounds in the Shadow Health Concept Labs and Physical Assessment Assignments are medically accurate.

Distinguishing normal from abnormal heart sounds requires practice and carefully listening for sometimes subtle and easily missed sounds. Be sure to take advantage of the Cardiovascular Concept Lab to sharpen your skills prior to beginning this assignment. Brian Foster Chest Pain Shadow Health Assessment

Optimize your listening experience by using headphones with your computer and listen to both normal and abnormal sounds multiple times to improve your proficiency with recognizing subtle differences.

Often patients present with a specific complaint or problem. However, during the history and physical examination, a new problem may be discovered that takes precedence during the visit. Be alert to such a situation with this case study assignment.

Purposes

The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the individual needs of the patient, (d) apply assessment skills and techniques to gather subjective and objective data, (e) differentiate normal from abnormal physical examination findings, (f) summarize, organize, and appropriately document findings using correct professional terminology, (g) practice developing primary and differential diagnoses, (h) practice creating treatment plans which include diagnostics, medication, education, consultation/referral, and follow-up planning; and (i) analyze and reflect on own performance to gain insight and foster knowledge.  Brian Foster Chest Pain Shadow Health Assessment.

Subjective Data Collection: 30 of 30 (100.0%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

• Found: Indicates an item that you found.
• Available: Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

• Finding: Established chief complaint

• Finding: Reports sporadic chest pain(Found)
  • Pro Tip: Chest pain can be a sign of many health problems, some serious and some less serious. It is important to follow up with discovery of chest pain by asking about its characteristics and severity. Brian Foster Chest Pain Shadow Health Assessment.
  • Example Question: Do you have chest pain?

History of Present Illness

• Finding: Asked about onset of pain

• Finding: Reports chest pain started appearing in the past month(Found)
  • Pro Tip: Establishing the onset of a patient’s pain is essential in diagnosing its severity as well as the comfort of the patient.
  • Example Question: When did your chest pain start?

• Finding: Asked about location of pain

• Finding: Reports pain is in center of the chest(Found)
  • Pro Tip: Identifying the location of a patient’s pain is essential in determining which body systems are affected, the underlying cause of the pain, and how best to treat it. Brian Foster Chest Pain Shadow Health Assessment.
  • Example Question: Where is the pain?
• Finding: Reports pain does not radiate(Found)
  • Pro Tip: Pain radiation is an important symptom that can be helpful in understanding the cause of pain and narrowing the diagnosis.
  • Example Question: Does the pain radiate?
• Finding: Denies arm pain(Found)
  • Pro Tip: When combined with chest pain, arm pain can be a telling sign that the complaint may be cardiac in nature.
  • Example Question: Are you experiencing arm pain?
• Finding: Denies shoulder pain(Found)
  • Pro Tip: When combined with chest pain, shoulder pain can be a telling sign that the complaint may be cardiac in nature.
  • Example Question: Are you experiencing shoulder pain?
• Finding: Denies back pain(Found)
  • Pro Tip: When combined with chest pain, back pain can be a telling sign that the complaint may be cardiac in nature.
  • Example Question: Are you experiencing back pain?
• Finding: Denies neck pain(Found)
  • Pro Tip: When combined with chest pain, neck pain can be a telling sign that the complaint may be cardiac in nature.
  • Example Question: Are you experiencing neck pain?

• Finding: Asked about duration of pain episodes

• Finding: Reports each episode lasted “several” minutes(Found)
  • Pro Tip: Knowing the duration of a patient’s pain gives you a more complete picture of its severity and potential impact on the patient’s health.
  • Example Question: How long does your chest pain last?

• Finding: Asked about frequency of pain

• Finding: Reports 3 episodes in past month(Found)
  • Pro Tip: Establishing a timeline for a patient’s symptoms can help you to better diagnose his condition and most effectively treat him.
  • Example Question: How many times in the last month have you had chest pain?
• Finding: Reports that episodes did not seem related(Available)
  • Pro Tip: Asking your patient if the episodes seem associated can point to possible factors that aggravate the episodes or trigger symptoms, and can help narrow your diagnosis. Brian Foster Chest Pain Shadow Health Assessment
  • Example Question: Did the episodes seem associated?

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• Finding: Asked about severity of pain

• Finding: Reports current pain is 0 out of 10(Found)
  • Pro Tip: For many patients, it is difficult to clearly describe pain. Asking Brian to rate his pain on a scale from 0 to 10 develops a consistent measure of pain severity.
  • Example Question: How would you rate your pain on a scale of zero to ten?
• Finding: Reports pain severity at its worst is 5 out of 10(Found)
  • Pro Tip: For many patients, it is difficult to clearly describe pain. Asking Brian to rate his pain at its worst gives a clearer picture of the pain’s severity.
  • Example Question: How would you rate your pain on a scale of zero to ten?

• Finding:Asked about character of pain

• Finding: Describes pain as tight and uncomfortable(Found)
  • Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
  • Example Question: Can you describe your pain?
• Finding: Denies crushing pain(Found)
  • Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
  • Example Question: Is the pain crushing?
• Finding: Denies gnawing pain(Found)
  • Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning. Brian Foster Chest Pain Shadow Health Assessment
  • Example Question: Is the pain gnawing?
• Finding: Denies burning pain(Found)
  • Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
  • Example Question: Is the pain burning?

• Finding: Asked about aggravating factors

• Finding: Reports pain is aggravated by activity(Found)
  • Pro Tip: Aggravating factors reveal further information about the nature of the pain and the body systems affected.
  • Example Question: What makes the pain worse?
• Finding: Pain occurred with yard work and taking stairs(Found)
  • Pro Tip: Determining the activity that may have caused the patient’s complaint is crucial because it may reveal the root cause of the complaint.
  • Example Question: What activity triggered the pain?
• Finding: Pain does not worsen with eating(Available)
  • Pro Tip: It is important to ask about the patient’s diet and its impact on his complaint because cardiac complaints and gastrointestinal pain can be very similar and are frequently conflated. Ruling out one or the other can assist your diagnosis.
  • Example Question: Is the pain worse when you eat?
• Finding: Pain does not worsen after spicy foods(Available)
  • Pro Tip: It is important to ask about the patient’s diet and its impact on his complaint because cardiac complaints and gastrointestinal pain can be very similar and are frequently conflated. Ruling out one or the other can assist your diagnosis.
  • Example Question: Is the pain worse after you eat spicy food?
• Finding: Pain does not worsen after high-fat foods(Found)
  • Pro Tip: It is important to ask about the patient’s diet and its impact on his complaint because cardiac complaints and gastrointestinal pain can be very similar and are frequently conflated. Ruling out one or the other can assist your diagnosis.
  • Example Question: Is the pain worse after you eat high-fat foods?

• Finding: Asked about relieving factors

• Finding: Reports pain relief with brief period of rest(Found)
• Pro Tip: It’s important to assess the nature of pain by asking about relief. Relieving factors can help narrow the body system and assist in a more accurate diagnosis. Brian Foster Chest Pain Shadow Health Assessment.
  • Example Question: What relieves your pain?
• Finding: Reports no medication to treat chest pain(Found)
  • Pro Tip: It’s important to assess the nature of pain by asking about relief. Discovering any pain medication Brian takes can help you assess the nature and severity of his pain and avoid any unwanted medication interactions. Brian Foster Chest Pain Shadow Health Assessment
  • Example Question: Did you take anything for the chest pain?

Medical History

• Finding: Confirmed use of medications

• Finding: Confirms medications(Found)
  • Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.
  • Example Question: What medications do you take?
• Finding: Reports taking hypertension medication(Found)
  • Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
  • Example Question: Do you take medication for hypertension?
• Finding: Reports taking hyperlipidemia medication(Found)
  • Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
  • Example Question: Do you take medication for hyperlipidemia?
• Finding: Reports occasional ibuprofen use(Available)
  • Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
  • Example Question: Do you take over the counter medications?
• Finding: Reports taking fish oil(Found)
  • Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication or supplements will help you to treat your patient.
  • Example Question: Do you take any supplements?
• Finding: Denies aspirin regimen(Available)
  • Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
  • Example Question: Do you take aspirin?

• Finding: Followed up on hypertension treatment

• Finding: Medication is Lopressor(Found)
  • Pro Tip: Discovering which specific medications a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions.
  • Example Question: What medication do you take for hypertension?
• Finding: Lopressor dose is 100mg(Found)
  • Pro Tip: The current dose of any patient’s prescription medications is important to learn about because it provides useful information about the patient’s treatment plan as well as potential medication interactions.
    • Example Question: What dose of medication do you take for hypertension?
• Finding: Takes Lopressor once daily(Found)
  • Pro Tip: The frequency with which a patient takes his medications is an essential element of the complete picture of his medication treatment plan. Brian Foster Chest Pain Shadow Health Assessment
  • Example Question: How frequently do you take medication for hypertension?

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Finding: Followed up on hyperlipidemia treatment

• Finding: Medication is Lipitor(Found)
  • Pro Tip: Discovering which specific medications a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions. Brian Foster Chest Pain Shadow Health Assessment
  • Example Question: What medication do you take for hyperlipidemia?
• Finding: Lipitor dose is 20mg(Found)
  • Pro Tip: The current dose of any patient’s prescription medications is important to learn about because it provides useful information about the patient’s treatment plan as well as potential medication interactions.
  • Example Question: What dose of medication do you take for hyperlipidemia?
• Finding: Takes Lipitor once daily(Found)
  • Pro Tip: The frequency with which a patient takes his medications is an essential element of the complete picture of his medication treatment plan.
  • Example Question: How frequently do you take medication for hyperlipidemia?
• Finding: Takes Lipitor at bedtime(Available)
  • Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication information, like at what time of day Brian takes Lipitor, will help you to treat your patient. Brian Foster Chest Pain Shadow Health Assessment
  • Example Question: What time of day do you take your Lipitor?
• Finding: Has taken Lipitor for 1 year

Objective Data Collection: 30 of 33 (90.91%)

•  Correct
•  Partially correct

•  Incorrect
•  Missed

 Inspected face1 of 1 point

Appearance (1/1 point)

•  No visible abnormal findings
•  Rash or lesion
•  Cyanosis
•  Pallor
•  Redness or flushing
•  Evidence of trauma (scar, laceration, or bruising)

 Inspected for jugular venous distension1 of 1 point

Height Of Venous Pressure (1/1 point)

•  4 cm or less above the sternal angle
•  More than 4 cm above the sternal angle

 Inspected chest1 of 1 point

Symmetry (1/2 point)

•  Symmetric
•  Asymmetric

Appearance (1/2 point)

•  No visible abnormal findings
•  Rash or lesion
•  AP diameter abnormal
•  Intercostal retraction while breathing
•  Excessive use of accessory muscles while breathing
•  Pectus excavatum
•  Skin growths (freckles or moles)
•  Evidence of skin trauma (scar, laceration, or bruising)

 Inspected abdomen0.67 of 1 point Inspected hands and fingernails1 of 1 point

Right: Appearance (1/4 point)

•  No visible abnormal findings
•  Redness
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Rash

Right: Nail Changes (1/4 point)

•  No visible abnormal findings
•  Pallor
•  Cyanosis
•  Splinter hemorrhages
•  Clubbing

Left: Appearance (1/4 point)

•  No visible abnormal findings
•  Redness
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Rash

Left: Nail Changes (1/4 point)

•  No visible abnormal findings
•  Pallor
•  Cyanosis
•  Splinter hemorrhages
•  Clubbing

 Inspected lower extremities and toenails1 of 1 point Inspect lower extremities for edema1 of 1 point Tested capillary refill time1 of 1 point

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Education & Empathy : 5 of 6 (83.3%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

• Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
• Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
• Brian Foster Chest Pain Shadow Health Assessment
• Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient Brian Foster Chest Pain Shadow Health Assessment

 1 Symptoms Followed Up 

2 Hypertension and High Cholesterol Followed Up 

3 Exercise Followed Up

4 Diet Followed Up

5 Weight Gain Not Encountered 

6 Family History Followed Up

Documentation / Electronic Health Record

• Document: Vitals

Vitals
Blood Pressure	Left Arm BP 146/88; Right Arm BP 146/90
O2 Sat	98%
Pulse	104 BPM
Resp. Rate	19
Temperature	36.7C

Document: Provider Notes

T

The patient reports to the clinic because of chest pains xxxxx. He reports experiencing xxxxx. He describes the chest pain xxxxx. . He denies heartburn xxxx	Return to Canvas to complete your SOAP note for this assignment.
ObjectiveGeneral Survey:Respiratory: Breathing is xxx.Gatrointestital: Round, xx. No xxxx. Tymphanic throughout. xxx palpable xxxx. Neuro: Alert and oriented. xxxx all extremities. Skin: Warm, pink, xxx tenting. EKG: Regular	Return to Canvas to complete your SOAP note for this assignment.
AssessmentDiagnosis; 1. Angina basal pectori xxx

Self-Reflection Activity Time: 8 min

Explain the clinical reasoning behind your decisions and tasks.

Student Response: xxxthe xxx

Explicitly describe the tasks you undertook to complete this exam.

Student Response: xx used xxx

What data did you use to base your decisions on for this patient assessment?

Brian Foster Chest Pain Shadow Health Assessment