ntroduction
In this paper, the author discusses the assessment of a 58-year-old who had periodic chest pains. Patients presenting with chest pain without a trauma history comprise the majority of those who visit emergency rooms and primary care settings. It is possible to determine the etiology of chest pain from a patient’s history and the most vital part in describing the characteristics of pain is its relieving and aggravating factors. NPs must be able to systematically evaluate other aspects such as the characteristic of pain which is crucial for developing a list of the most probable causes, guides the physical exam, and choice of diagnostic tests.Focused Health History and Physical Assessment-Chest Pain.
The focus of the Assessment
This assessment focuses on a 58-year-old patient who had a complaint of constant chest pain. The author discusses the history taking, physical examination, and assessment based on the complaint of chest pains to make an accurate diagnosis and care plan. In the clinical history, the author focuses on the characteristics of chest pain and assesses it further using the PRST pain assessment tool, the past medical history (history of pulmonary or vascular disease, allergies, and underlying chronic illnesses), social history(use of illicit drugs, tobacco, and alcohol), and family history(familial history of chronic cardiovascular illnesses). The physical exam focuses on the presence of carotid upstroke, cyanosis, signs of peripheral edema, lung sounds, pulses, use of accessory muscles, and distress.Focused Health History and Physical Assessment-Chest Pain.
Subjective Component
CC-chest pain
HPI-the patient is a 58-year-old day complaining of chest pain that started early during the month. He describes the pain as squeezing pressure, rates its severity as 5/10, and explains that it was localized at the mid-sternum. Apart from being constant, he explains that it increased in severity. He associated the pain with left shoulder pressure and onset nausea but denied emesis. The pain lasts for several minutes, is aggravated by physical activity, and is relieved by resting. This month, he reports that he experienced the pains three times.Focused Health History and Physical Assessment-Chest Pain.
Medications: Metoprolol (Lopressor) 100mg PO OD, atorvastatin (Lipitor) 20 mg PO OD, Omega-3 Fish Oil 1200 mg PO, ibuprofen 800mg BID.
Allergies: medications; codeine-nausea and vomiting, environment-none, food-none.
Past Medical and Surgical History: the patient is up to date with all immunizations. Recently, he received influenza and Tdap. He was also diagnosed with hyperlipidemia and stage II hypertension one year ago but has never been diagnosed with angina or have a significant surgical history. He reported no significant surgical history or diagnosis with angina. Mr. Foster has no history of DM or has previously been managed for CP. He does not monitor his BP at home and no knowledge about his typical BP. His last stress test and EKG were three months ago. His last visit to a PCP was three months ago and he did see a cardiologist.
Social History: he reported no presence or history of illicit or tobacco use, consumes between 2-3 beers over the weekends, and currently, he states that he has a low lifestyle and job stress. Mr. Foster denies performing regular physical activity since his bike was stolen. For most of his breakfasts, he takes a breakfast shake or granola bar, for lunch, he takes Italian salad or sub, and grilled meat with vegetables for dinner. Over the weekend, he emphasizes taking big breakfasts. However, he rarely monitors his intake of drinks and salt since he consumes two cups of coffee daily, 1L of water, and a whole pot of coffee on Sundays. However, he does not consume soda.Focused Health History and Physical Assessment-Chest Pain.
Family History: The patient’s father is deceased (at 75 years) due to colon cancer. He also had hyperlipidemia, hypertension, and obesity. His mother (80 years) was diagnosed with type 2 DM and hypertension, the maternal grandfather died of MI but there is no familial history of stroke or PE. His brother (24) and sister (52) are deceased to an MVA, and hypertension/type 2DM related complications respectively. Mr. Foster’s maternal grandmother died at 65 secondary to breast CA related complications. Maternal grandfather deceased at 54 (MI), paternal grandmother deceased at 78 (PNA), paternal grandfather deceased at 85. Mr. Foster’s son alive and healthy, presently 26 years old, his da
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