Description
I attachedmy template I need you to do only these 2 parts
Diagnostic Test/Labs: Diagnostic Test/Labs: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses with rationale for each one documented OR ones that were mentioned during
the SH assignment
12-lead ECG ·
Chest X-ray ·
lab workup (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1C, lipid profile, and liver function tests)
Echocardiogram, ·
Exercise Stress Test Carotid Dopplers
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.
1. coronary artery disease with stable angina;
2. congestive heart failure;
3. carotid disease;
4. aortic aneurysm;
5. pericarditis
also they have to be cited and use DOI for the last 5 years so from 2019 (So each on from Diagnostic Test/Lab and ASSESSMENT) has to have at least 2 references and medical facts need to be cited
each lab need to talk about it and why we perform this lab work and how relates to the patient case also the differential diagnosis should be related to the patient so when u talk about each diagnosis u have to connect to the patient case and this is the patient case study (so please read the HPI for the patient and make the connections in the diagnostic lab and assessment (differential diagnosis the 5 diagnosis) see the attached file and fill in it
History of Present Illness (HPI): Mr. Foster is a 58-year-old Caucasian male who presents to the clinic with having some intermittent troubling chest pain in his chest now and then for the past month, happened three times in the last month only lasting a few minutes. Patient thought it might have been heartburn passing after a few minutes. He reports current pain level as a 0/10 at its worst a 5/10. He describes the pain in the middle of his chest feels tight and uncomfortable, denies pain radiating. Patient says the pain feels better when he is lying still and feels its worst when he is doing something physical such as yard work or walking up the stairs. He also mentioned after eating too much he felt chest tightness.
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Name:
Section:
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain
Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): Chest pain.
History of Present Illness (HPI): Mr. Foster is a 58-year-old Caucasian male who presents to the clinic
with having some intermittent troubling chest pain in his chest now and then for the past month,
happened three times in the last month only lasting a few minutes. Patient thought it might have
been heartburn passing after a few minutes. He reports current pain level as a 0/10 at its worst a
5/10. He describes the pain in the middle of his chest feels tight and uncomfortable, denies pain
radiating. Patient says the pain feels better when he is lying still and feels its worst when he is doing
something physical such as yard work or walking up the stairs. He also mentioned after eating too
much he felt chest tightness.
1.
Location: middle of chest
2.
Quality: Tight and uncomfortable
3.
Quantity or severity: 5/10
4.
Timing, including onset, duration, and frequency:
Onset month ago.
Duration lasting a few minutes.
Frequency about 3 times.
5.
Setting in which it occurs: While engaging in home gardening tasks and walking at the
workplace
6.
Factors that have aggravated or relieved the symptom: Pain alleviated while laying down,
exacerbated by engaging in physical activities.
7.
Associated manifestations: While engaged in yard work and climbing stairs at the workplace
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with
dosage and frequency.
© 2021 Walden University
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•
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Lisinopril (Prinivil) 20mg PO daily
Omega-3 Fish Oil 1200mg PO BID
Atorvastatin (Lipitor) 20mg PO daily at bedtime
Diagnostic Test/Labs: Diagnostic Test/Labs: Include any labs, x-rays, or other
diagnostics that are needed to develop the differential diagnoses with rationale for
each one documented OR ones that were mentioned during
the SH assignment
•
•
•
•
•
•
12-lead ECG
Chest X-ray
lab workup (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1C, lipid profile, and liver
function tests)
Echocardiogram,
Exercise Stress Test
Carotid Dopplers
ASSESSMENT: List your priority diagnosis(es). each of which must be supported with evidence and
guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are
controlled or not controlled.
Differential Diagnosis
1. coronary artery disease with stable angina;
2. congestive heart failure;
3. carotid disease;
4. aortic aneurysm;
5. pericarditis
© 2021 Walden University
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