Advanced Health Assessment
Advanced Health Assessment and Diagnostic Reasoning
Brian Foster
FOCUSED EXAM CHEST PAIN SUBJECTIVE DATA CC:
“I have been hurting in my chest for about a month.”
History Present Illness:
Brian Foster is a 58-year-old white American male. He presents to the clinic with intermittent chest pain for about a month. He reports the pain substernal with some tightness. He reports the pain during exertion and subsides with rest. He rates the pain a 5/10. He denies any cardiac history. He denies nausea and vomiting. He denies any shortness of breath. He denies taking any medication for the pain.
Medications:
- Metaprolol 100mg PO daily
- Atorvastatin 20mg PO daily HS. The last dose at 8 pm yesterday.
- Omega 3 Fish Oil 1200mg PO BID. The last dose at 8 am this morning.
Allergies: Codeine- severe nausea and vomiting, NKFA, Denies any latex allergy.
Immunization History: Tdap (2014), Flu vaccine this season
Past Medical History (PMI): Hypertension diagnosed a year ago- controlled with medications. Hyperlipidemia diagnosed a year ago- controlled with medication.
Surgical History: He denies any surgeries.
Family History: Father: Hypertension, Hyperlipidemia, Obesity, Deceased at the age of 75 with colon cancer. Mother: Type II Diabetes and Hypertension Brother: Died at the age of 24 in a motor vehicle accident (MVC). Sister: Type II Diabetes and Hypertension Maternal Grandmother: Died at the age of 65 with breast cancer. Maternal Grandfather: Died at the age of 54 of myocardial infarction. Paternal Grandmother: Died at the age of 78 with pneumonia. Paternal Grandfather: Died at the age of 85 of natural causes.
Social History: He is married with two children ( a son and a daughter). He denies any past or current tobacco use. He reports drinking 2-3 alcoholic drinks per week. He denies any illicit drug use. He is an engineer and enjoys gardening.
Review of Systems (ROS) General: A & O X 4. Calm and cooperative. Brian reports weight gain of 20lbs within the past couple of years
HEENT Head: Denies any dizziness. Denies any visual changes. Reports last eye exam eight months ago. Denies any nasal drainage. Denies any difficulty swallowing. Denies a sore throat. Neck: Denies any neck pain.
Cardiovascular: Reports, pain and tightness substernal. Denies palpitations. Denies history of angina. Denies any edema. Respiratory: Denies any shortness of breath. Denies a cough. Gastrointestinal: Denies any nausea, vomiting, or diarrhea. Denies any heartburn. Neurological: Denies any dizziness. Denies any headaches. Musculoskeletal: Denies any back pain or stiffness. Hematologic: Denies any bleeding or bruising.
OBJECTIVE DATA
Vital signs: BP 146/90 right arm, sitting, automatic; HR 104 tachycardiac; RR 19 even and nonlabored; Temp 98.6 orally; O2 sat 98%; WT 197lbs; HT 5’11”
General: A & O X 4. Skin warm and dry. No tenting noted. Well-groomed. Normal gait. Speech is clear and concise. Brian exhibits no signs of any acute distress.
HEENT: Head is symmetrical with no abnormal findings. PERRLA X 4. Neck: Supple with no tenderness. No jugular vein is noted. JVD is 3cm above the sternal angle. Bruit with a positive thrill and amplitude of 3+ at the right carotid artery. No bruit auscultated in the left carotid. No thrill. The amplitude of 2+.
Chest: Symmetrical with no anatomical findings. PMI displaced less than 3cm with brisk tapping.
Abdomen: Symmetrical and normoactive bowel sounds in all quadrants. No bruits noted. No tenderness or masses palpable. Liver is palpable at 6-12cm. Spleen is not palpable. Cardiovascular: S1, S2, and S3 audible. Gallops heard on auscultation. Tachycardic.
Pulmonary: Breath sounds present in all fields. Adventitious sounds fine crackles auscultated in the right and left lower lobes.
Peripheral Vascular: No edema noted to bilateral upper and lower extremities. Brachial pulses palpable with no thrill and 2+. Radial pulses palpable with no thrill and 2+. Femoral pulses palpable with no thrill and 2+. Popliteal pulses palpable with no thrill and 1+. Tibial pulses palpable with no thrill and 1+. Distal pulses palpable with no thrill and 1+. Capillary refill < 3sec brisk.
EKG: Normal Sinus Rhythm with no ST elevation.
ONLY 3 Differential Diagnoses ARE NEEDED FOR THIS PAPER
- Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned
- Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
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v Written Expression and Formatting – English Writing Standards:
Correct grammar, mechanics, and proper punctuation
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
v You must include in text citations for all non-original assertions.
How do you know? Please Reference?
v Please make sure to include a reference for all non-original assertions, even in your conclusion.
v Please do not use bullet points in your papers. I would like to see narrative in your scholarly papers
v Please make sure to include primary sources that have been published in the past 5 years to support your assertions in the paper. Remember, websites like the Mayo Clinic are not primary sources. Please also make sure to review the rubric for the assignment and use it to guide your
paper.
As advanced practice nurses, we are scholars, nurse researchers and scientists. As such, please use Peer-Reviewed scholarly articles and websites designed for health professionals (not designed for patients) for your references. We should also use these scholarly works as a basis for our patient education and recommendations to patients in the clinical setting. Even some resources written for professionals, such as Up to Date, these are not admissible as a scholarly reference. Students should be using the original citation.
The following are examples (not all inclusive) of resources/websites deemed inadmissible for scholarly reference:
1. Up to Date (must use original articles from Up to Date as a resource)
2. Wikipedia
3. Cdc.gov- non healthcare professional’s section
4. Webmd.com
5. Mayoclinic.com