The Childhood Immunization Essay

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Shadow Health Digital Clinical Experience Focused Exam: Chest Pain

Documentation

SUBJECTIVE DATA:
Chief Complaint (CC): “I have been having some troubling chest pain in my chest now and then for the
past month.”
HPI: The client Brian Foster is a 58-year-old, Caucasian man who presents with chest pain intermittently
which he reports has been going on for the past month. He describes the pain as an uncomfortable and
tight feeling in the chest above his heart, which does not radiate to the back or arms. He rates the
intermittent chest pain as 5 on a scale of 10 when is occurs. B.F reveals that he first experienced the
pain while working in the yard. The second time he experienced the pain while climbing stairs at work.

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/D.

Medications:
1. Atorvastatin 20 mg orally once a day,
2. Lisinopril 20mg orally every day,
3. Omega-3 fish oil 1200mg orally twice a day.
4. Tylenol for managing headaches.
Allergies: Reports being allergic to codeine. “It makes me nauseous, and I vomit.”
Past Medical History (PMH): The client reports a history of hypertension and high cholesterol, which
were diagnosed last year.
Past Surgical History (PSH): The client denies any surgery.
Sexual/Reproductive History: Married with a daughter.

Personal/Social History: The client consumes 2-3 beers on the weekend. Denies tobacco or illicit drugs
use. He denies any stressors. He engaged in bike riding until his bike was stolen, but currently does not
engage in exercise or physical activities regularly. He reports eating a healthy diet. The client reported The Childhood Immunization Essay

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undergoing stress tests and EKGs annually and the results were normal. He reports visiting his primary
care provider every six months.

Immunization History: The client’s childhood immunization are updated. He received the flu vaccine last
year.

Significant Family History: The client reports that his father had been diagnosed with hyperlipidemia,
hypertension, and obesity. He died of colon cancer at 75 years. His mother is 80yo and has hypertension
and type 2 diabetes (T2DM). Similarly, his sister has been diagnosed with T2DM and hypertension. He
adds that his brother died in a car accident at age 24 and his maternal grandfather died of a heart attack
in his mid-fifties. The Childhood Immunization Essay

Review of Systems:
General: Client is dressed appropriately for the visit. He is anxious about the pain in his chest but
otherwise no distress noted. He denies fever and N/V/D.
Cardiovascular/Peripheral Vascular: Currently, the client denies chest pain. He reposts tightness in the
chest that occurred last month. He added that chest pain occurs while engaging in activity such as yard
work and walking up stairs. Reports pain reduces upon lying down.
Respiratory: Denies sputum production or cough.
Gastrointestinal: Denies constipation, nausea, or vomiting.
Musculoskeletal: Denies joint pain, back pain, or joint swelling.
Psychiatric: Denies insomnia or suicidal thoughts. The Childhood Immunization Essay
OBJECTIVE DATA:
Physical Exam:
Vital signs: BP 146/90, Pulse 104, O2 sat 98%, RR 19, Temp 36.7C, Weight: 197lbs, and Height: 5’ 11”
Cardiovascular/Peripheral Vascular: Bruit and thrill noted to right carotid , but no bruit and thrill note
to left carotid. S1, S2, and S3 auscultated, gallop noted.
Respiratory: Fine crackles noted to right and left posterior lower lobes. Denies cough or SOB.
Gastrointestinal: No blood in the stool. No constipation.
Musculoskeletal: Normal back curvature.
Neurological: Motor is 5/5 throughout
Skin: No abnormalities noted.

© 2021 Walden University
Diagnostics:
EKG: No ST changes. Normal Sinus was detected. The Childhood Immunization Essay
ASSESSMENT:
1. Angina Pectoris: This condition is the primary diagnosis for this client. It is characterized by
pressure, tightness, or discomfort in the chest that recurs over time. The pain is prompted by exertion or
physical exercise and relieved by lying down (Ford & Berry, 2020). The client has this condition since he
reported chest pain that increases with exercise and reduces upon lying down.
2. Coronary artery disease: This is another potential diagnosis for this client since it is
characterized by some reported symptoms, including pressure like chest pain, which radiates to the left
shoulder (Ford & Berry, 2020). However, it is ruled out since the client stated that the pain does not
radiate to the back. The Childhood Immunization Essay
3. GERD: This condition is characterized by a burning sensation in the chest and chest pain,
making swallowing difficult (Clarrett & Hachem, 2018). This condition is ruled out since the client denies
difficulty swallowing.
4. Acute Pericarditis: The client also qualifies for this diagnosis. This condition is characterized by
stabbing and sharp chest pain, which occurs quickly (Ismail, 2020). Nonetheless, this condition is ruled
out since the client’s pain does not occur quickly.
References
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri
medicine, 115(3), 214.
Ford, T. J., & Berry, C. (2020). Angina: contemporary diagnosis and management. Heart, 106(5), 387-398.
Ismail, T. F. (2020). Acute pericarditis: update on diagnosis and management. Clinical Medicine, 20(1),

Will you please re word his soap note but use the same info to prevent plagiarism when being submitted… thank you The Childhood Immunization Essay