Patient Information:
65 year Old AA male
S.
CC Chest pain.
HPI: The individual in this case is a 65 year Old AA male. The patient indicates that he developed an abrupt commencement of chest pain that commenced early in the morning. The patient indicates the pain as crushing and is ranked 9/10 in pain scale. The aching’s location is in the interior of the ribcage, and this is complemented by shortness of breath. On probing, the individuals indicated feeling nauseated. The individual has also tried medication such as antacid with negligible reprieve of his signs. The patient has a positive history of GERD and hypertension that have previously been controlled.
The patient also indicates the mother passed on at 78 of breast cancer, Father at 75 of CVA. The patient does not exhibit an account of untimely cardiac disease in first degree relations. The patient has been married for the last 39 years.
Location: Chest.
Onset: early in the morning.
Character: Crushing pain in the middle of the chest.
Associated signs and symptoms: nauseous without vomiting.
Timing: no sufficient information.
Exacerbating/ relieving factors: antacid with minimal relief of the symptoms.
Severity: 9/10 pain scale
Current Medications: antacids with minimal relief on the symptoms.
Allergies: No known allergies.
PMHx: positive history of GERD and hypertension is controlled.
Soc Hx: currently consumes moderate alcohol and negative for tobacco use.
Fam Hx: The mother passed on at 78 of breast cancer, Father at 75 of CVA. There is no account of untimely cardiac ailment in first degree.
ROS:
GENERAL: negative for fever, chills, fatigue.
HEENT: No evidence of HEENT examination.
SKIN: No evidence of skin examination.
CARDIOVASCULAR: negative for orthopnea, PND, positive for sporadic lower extremity edema.
RESPIRATORY: no evidence of respiratory examination.
GASTROINTESTINAL: positive for nausea without vomiting, negative for diarrhea, abdominal pain.
GENITOURINARY: not applicable.
NEUROLOGICAL: no evidence of neurological examination.
MUSCULOSKELETAL: no evidence of musculoskeletal examination.
HEMATOLOGIC: no evidence of hematologic examination.
LYMPHATICS: no report of lymphatic examination.
PSYCHIATRIC: no report of psychiatric examination.
ENDOCRINOLOGIC: no report of endocrinologic examination.
ALLERGIES: no report of allergies.
O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
Physical exam: The results of electrocardiography (EKG), chest radiograph (CXR), and CK-MB test, indicate that the lungs are clear to auscultation and percussion bilaterally. The Pt looks diaphretic and restless. PMI is in the 5th inter costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is perceived best at the second right inner costal space that discharges to the neck. A third heart sound is heard at the Apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+LE edema is noted.
The abdomen is proportioned devoid of distention, bowel noises are ordinary quality and concentration in all parts, a bruit is heard in the right para umbilical area. No masses or splenomegaly are eminent. Positive for mid-epigastric inflammation with profound palpation. The lungs are flawless to auscultation and percussion jointly.
Diagnostic results: EKG, CXR, CK-MB.
A.
Differential Diagnoses
The physical exam comprises of an active observational examination of the individual. According to Balogh, Miller, and Ball (2015), the nurse should first observe the patient’s behavior, complexion, posture, level or distress, and any other signs which might contribute to the understanding of the health of the patient. A physical exam can include the entire HEENT examination, which can assist the nurse to enhance the steps taken in the diagnostic process. In the long run, this can avert unnecessary diagnostic testing and build trust with the patient (Balogh, Miller & Ball, 2015). Some of the physical examinations that should be conducted on the patient can include the following.
First, inspection where the clinician can look at or inspect specific areas for abnormalities. Second, palpation where the nursing practitioner ca
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