Academic Clinical History and Physical
Complete an academic clinical history and physical note based on a patient seen during clinical/practicum. In your assessment, provide the following:
History and Physical Note
Chief complaint/reason for admission/visit/consult.
HPI for the H&P or consult notes.
Medical, surgical, family, social, and allergy history.
Home medications, including dosages, route, frequency, and current medications, if a consultation note.
Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).
Vital signs and weight.
Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.
Lab/Imaging/Diagnostic test results (including date).
Assessment and Clinical Impressions
Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale.
Include a complete list of all diagnoses that are both acute and chronic.
List the differential diagnoses and chronic conditions in order of priority.
Plan Component Management and Plan Criteria Incorporation
Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.
Discuss disposition and expected outcomes.
Identify and address health education, health promotion, and disease prevention.
Provide a case summary with ethical, legal, and geriatric considerations. Compare treatment options specific to the geriatric population to nongeriatric adult populations. Consider potential issues, even if they are not evident.
Clinical History and Physical Note: Patient’s Chief Complaint
Chief Complaint: Shortness of breath and chest pain.History of Present Illness
The patient, a 68-year-old male, presented to the emergency department with complaints of shortness of breath and chest pain that started about 6 hours ago. He describes the chest pain as a pressure-like sensation in the center of his chest, radiating to his left arm. The pain is intermittent and worsens with exertion. The patient also reports associated symptoms such as sweating and lightheadedness during episodes of chest pain. He denies any recent illnesses or injuries.Medical History
- Hypertension: Diagnosed 8 years ago, currently managed with Lisinopril 10 mg daily.
- Hyperlipidemia: Diagnosed 10 years ago, currently managed with Atorvastatin 40 mg daily.
- Type 2 Diabetes Mellitus: Diagnosed 6 years ago, currently managed with Metformin 1000 mg twice daily.
- Coronary Artery Disease: History of a myocardial infarction 3 years ago, treated with percutaneous coronary intervention (PCI) and placement of a drug-eluting stent in the left anterior descending artery.
- Chronic Kidney Disease: Stage 3, secondary to long-standing hypertension and diabetes.
- Asthma: Diagnosed in childhood, currently controlled with an albuterol inhaler as needed.
- Allergies: No known drug allergies.
Surgical History
The patient had a cholecystectomy for symptomatic gallstones 10 years ago. No other significant surgical history.Family History
- Father: Deceased at age 72 due to complications of a stroke.
- Mother: Alive, aged 75, with a history of hypertension and osteoporosis.
- Siblings: One brother with hypertension and hyperlipidemia, one sister with breast cancer (diagnosed at age 60).
Social History
The patient is married and lives with his wife. He is retired and used to work as a teacher. He denies tobacco or illicit drug use. He drinks alcohol socially, approximately 1-2 drinks per week. He follows a balanced diet and tries to engage in regular exercise, but has been less active lately due to his symptoms.Allergy History
The patient denies any known drug allergies.Home Medications
- Lisinopril 10 mg daily for hypertension.
- Atorvastatin 40 mg daily for hyperlipidemia.
- Metformin 1000 mg twice daily for diabetes.
- Albuterol inhaler as needed for asthma.
Review of Systems
- Cardiovascular: Chest pain, shortness of breath.
- Respiratory: Shortness of breath, wheezing (intermittent).
- Gastrointestinal: No abdominal pain, nausea, vomiting, or changes in bowel movements.
- Genitourinary: No dysuria, hematuria, or changes in urinary frequency.
- Musculoskeletal: No joint pain or limitations in mobility.
- Integumentary: No rashes or lesions.
- Neurological: No headaches, dizziness, or changes in sensation.
- Endocrine: No polyuria or polydipsia.
Vital Signs and Weight
- Blood Pressure: 138/82 mmHg
- Heart Rate: 76 bpm
- Respiratory Rate: 18 breaths per minute
- Temperature: 98.6°F (36.9°C)
- Oxygen Saturation: 96% on room air
- Weight: 185 lbs (84 kg)
Physical Exam
General: The patient appears comfortable but slightly anxious. He is alert and oriented. Head: Normocephalic, atraumatic. Pupils equal and reactive to light. No signs of facial asymmetry. Eyes: Conjunctiva pink. Sclera white. No conjunctival injection or discharge. PERRLA (pupils equal, round, reactive to light and accommodation). Ears: Bilateral canals clear. Tympanic membranes intact. Nose: No nasal discharge or bleeding. Throat: Oropharynx without erythema or exudates. Moist mucous membranes. Neck: Supple, no lymphadenopathy or thyromegaly. Carotid pulses are symmetric without bruits. Jugular venous distention is not present. Chest: Symmetric expansion. Auscultation reveals normal breath sounds bilaterally without wheezes or crackles. No abnormalities on percussion. Cardiovascular: Regular rate and rhythm. Normal S1 and S2 heart sounds. No murmurs, rubs or gallops appreciated. Abdomen: Soft, non-tender to palpation. No organomegaly or masses appreciated. Bowel sounds present in all four quadrants. Extremities: No edema or cyanosis. Full range of motion in all extremities. Skin: Warm and dry. No rashes or lesions noted.Lab/Imaging/Diagnostic Test Results
- EKG (12-Lead): Sinus rhythm with no ST-segment elevation/depression or T-wave changes.
- Troponin I Level: Pending.
Assessment and Clinical Impressions
Differential Diagnoses:- Acute Coronary Syndrome (ACS): Given the patient’s chief complaint of chest pain radiating to the left arm, associated symptoms such as sweating and lightheadedness, and the history of coronary artery disease with a previous myocardial infarction, ACS should be considered as the primary differential diagnosis.
- Acute Decompensated Heart Failure (ADHF): The patient’s shortness of breath could be due to worsening heart failure, especially considering the history of hypertension, diabetes, and stage 3 chronic kidney disease.
- Acute Exacerbation of Asthma: Although less likely given the patient’s history of stable asthma controlled with an albuterol inhaler, it cannot be completely ruled out as a contributing factor.
- Hypertension
- Hyperlipidemia
- Type 2 Diabetes Mellitus
- Coronary Artery Disease
- Chronic Kidney Disease (Stage 3)
- Asthma
Plan Component Management and Plan Criteria Incorporation
Diagnostic Interventions:- Serial Troponin Levels: To assess for myocardial injury and rule out acute myocardial infarction as the cause of the patient’s symptoms.
- Chest X-ray: To evaluate for signs of pulmonary congestion or other cardiopulmonary abnormalities.
- Echocardiogram: To assess cardiac function and evaluate for signs of heart failure or structural abnormalities.
- Oxygen Therapy: Administer supplemental oxygen to maintain oxygen saturation above 94%.
- Nitroglycerin Sublingual Spray: If the patient’s blood pressure remains stable, consider administering nitroglycerin sublingual spray for chest pain relief.
- Aspirin 325 mg Chewable Tablet: Administer aspirin as an antiplatelet agent to reduce the risk of further ischemic events.
- Albuterol Inhaler Treatment: If the patient’s symptoms are attributed to an acute exacerbation of asthma, administer albuterol inhaler treatments as needed.
- Medication Adherence: Reinforce the importance of taking prescribed medications regularly and as directed to manage chronic conditions effectively.
- Lifestyle Modifications: Discuss the significance of a heart-healthy diet, regular exercise, smoking cessation (if applicable), and stress reduction techniques to reduce the risk of future cardiac events.
- Follow-up Appointments: Emphasize the need for regular follow-up appointments with primary care provider and specialists to monitor chronic conditions and adjust treatment plans if necessary.