Myrnaivette Pierson Focused Note 04/28/19

Subjective:

Date of encounter: April 15, 2019

Patient Name or initials: Esther Park
Informant: 78-year-old woman, reliable historian
Chief Complaint: “I have some pain in my belly and I’m having trouble going to the
bathroom.”
History of present illness:

Allergies:
 Codeine: causes nausea and vomiting
Medications:
 Prescription
Metoprolol (Lopressor) 100mg PO daily, HTN
Atorvastatin (Lipitor) 20mg PO daily, Hyperlipidemia
 OTC Supplements
Omega-3 Fish Oil 1200mg PO BID, Hyperlipidemia
 Herbal Supplements
None
Past History:
 Hypertension: Stage II, diagnosed one year ago
 Hyperlipidemia: diagnosed one year ago
 No surgical history
Family History:
 Father: HTN, hyperlipidemia, obesity, died of colon cancer, age 75
 Mother: Type II DM, HTN, age 80
 Brother: died in MVA, age 24
 Sister: Type II DM, HTN, age 52
 Maternal grandmother: died of breast cancer, age 65
 Maternal grandfather: died of heart attack, age 54
 Paternal grandmother: died of PNA, age 78
 Paternal grandfather: died of “old age”, age 85
 Son: healthy, age 26
 Daughter: Asthma, age 19
Personal and Social History:
 No past or present tobacco use
 Reports drinking 2-3 alcoholic drinks (beer) per week
 Denies use of marijuana, cocaine, heroin or other illicit drugs

Pertinent Review of systems:

 General: 58-year-old Caucasian male. Reports being “healthy and in pretty good
shape most of my life.” Gained 20lbs over last couple of years. Last physical
exam 3 months ago
 Respiratory: No shortness of breath when having chest pain. Denies coughing up
Myrnaivette Pierson Focused Note 04/28/19

blood, allergies, asthma and exposure to second hand smoke

 Cardiovascular: Diagnosed with HTN and hyperlipidemia one year ago. Reports
chest tightness and sharp pain to the middle of chest. No heart palpitations and
murmurs. EKG and stress test 3 months ago, results normal
 Gastrointestinal: Reports that he thought he had heartburn when experiencing
chest tightness. No stomach problems
 Peripheral Vascular: No leg pain, cramps, weakness, swelling, coldness or sores
 Musculoskeletal: No trauma or injury while doing yard work

SUBJECTIVE REFLECTION:
Interaction with patient was concise and productive with the patient answering all
questions completely and with some detail. Other questions could include:
When was your last blood tests done? Trending lipid and triglyceride levels
would help to diagnose possible vessel occlusions and assist in plan of care if
medications need to be adjusted.
Have you had an echocardiogram done? An echocardiogram would help to
diagnose defects in the function and structure of the heart. It would help to identify
possible vessel occlusion.
Have you had problems with thinking, awareness, attention, learning, judgement
or memory? Since patient has right carotid bruit there is risk of stroke or TIA.

Objective:

Vital Signs:
 Left arm B/P: 146/88, Right arm B/P: 146/90
 O2 Sat: 98%
 Pulse: 104
 RR: 19
 Temp: 36.7c
Height: 5’11”
Weight: 197lbs
BMI: 27.5 (overweight)

Physical Exam:
Constitutional/General survey
 58-year-old Caucasian male is alert and oriented, good eye contact, clear
speech and pleasant. Clean and well groomed. No acute distress.

Neck
 Right carotid pulse with thrill, 3+ and bruit
 Left carotid pulse without thrill, 2+, no bruit
Thorax and Lungs
 Thorax is symmetrical with equal bilateral excursion
Myrnaivette Pierson Focused Note 04/28/19

 Breath sounds are clear to auscultation in anterior upper lobes and right
middle lobe
 Fine crackles bilaterally in posterior bases noted on inspiration
Cardiovascular
 S1, S2, S3 (gallop) noted at mitral area without murmurs or rubs
 PMI displaced laterally, brisk and tapping, less that 3cm in diameter
 No jugular vein distention. JVP 3 cm above sternal angle
 Auscultated right carotid bruit palpable 3+ thrill
 Palpation of carotid arteries, R carotid pulse: thrill, 3+, L carotid pulse: no
thrill, 2+
 Capillary refill less than 3 in all four extremities
 EKG (interpretation): Regular Sinus Rhythm. No ST changes
Abdomen
 Abdomen round, soft, non-tender with normoactive BS x 4 quadrants; no
abdominal bruits
 No tenderness to light or deep palpation. Tympanic throughout
 Liver is 7cm at the mid-clavicular line and 1 cm below right costal margin
 Spleen and bilateral kidneys are not palpable
Peripheral vascular:
 Extremities are without varicosities, edema or stasis
 No bruit in femoral artery
 Brachial, radial, femoral pulses without thrill, 2+
 Popliteal, dorsalis pedis, and posterior tibial pulses without thrill 1+
Musculoskeletal:
 Full range of motion to all extremities

OBJECTIVE REFLECTION:
Working with an avatar is more difficult than a human patient. It is easier to have
a patient perform movements and simple tasks. There are also nuances to a patient’s
speech or reactions in an interview that are missing with an avatar.

Assessment:

Diagnosis:
Stable angina presentation suggestive of Coronary Artery Disease: chest
discomfort that increases with exertion and decreases with rest is highly
suggestive of myocardial ischemia
Differential Diagnoses:
 Congestive heart failure: Fatigue with exertion and comfortable at rest
Crackles on inspiration could indicate left ventricular hypertrophy
 Carotid atherosclerotic disease: Right sided carotid bruit noted during
auscultation. Indicated by age, hypertension, hyperlipidemia, obesity and
family history
 Costochondritis: doing yard work, pulling up weeds
 Gerd: chest pain after eating large meal
Myrnaivette Pierson Focused Note 04/28/19

Plan:

Diagnosis studies:
 12 lead EKG: decrease of left ventricle perfusion
 Chest x-ray: assess heart size, pulmonary artery dilation and lung
consolidation
 Graded exercise test: determine angina and safe exercise levels
 Echocardiogram: identify structural and functional heart abnormalities
 Carotid ultrasound: determine narrowing or blockages of carotid arteries
Diagnostics labs:
 Cardiac enzymes, troponin to evaluate for cardiac muscle damage
 CMP:14 tests to evaluate current status of metabolism, kidney function,
liver function, electrolytes, acid/base balance, glucose and blood proteins
 Lipid panel to evaluate cholesterol
Pharmacology:
 Nitroglycerin 0.4 mg up to 3 times five minutes apart sublingual PRN for
angina
 Furosemide 20 mg PO once daily for CHF
 Diltiazem 60 mg PO BID for hypertension and angina
 Aspirin 81 mg PO once daily for asymptomatic carotid atherosclerotic
disease
 Continue Metoprolol (Lopressor) 100 mg PO daily for HTN
 Continue Atorvastatin (Lipitor) 20 mg PO daily for Hyperlipidemia
 Continue Omega-3 Fish Oil 1200 mg PO BID for Hyperlipidemia
Education/Counseling:
 Explanation of each diagnostic procedure and its purpose
 Lab work and how they apply to patient’s condition
 Coronary artery disease and its relationship to hypertension and
hyperlipidemia
 Identifying when to seek emergency medical attention related to chest pain
 Medication counseling for compliance and side effects of new medications
 Stress reduction for control of hypertension
 Exercise/weight loss goals to control hypertension and hyperlipidemia

Health Promotion/Anticipatory Guidance:

 Dietary for weight management. Avoid eating large meals
 Light exercise 3-4 days per week will increase muscle tone
 Decrease or eliminate alcoholic beverage consumption to improve HTN

Referrals:
 Cardiology for primary diagnosis of coronary heart disease and CHF.
 Vascular surgeon for carotid evaluation
 Nutritionist for cardiac diet and lifestyle modifications
Myrnaivette Pierson Focused Note 04/28/19

Follow-up:
 Two weeks for lab test result evaluation
 One month for diagnostic study results and evaluation of medications

Self-Assessment:

Mr. Foster was easy to interview. An adequate health history and physical
examination was performed. The assessment involved all pertinent systems. I felt that
the patient’s hypertension could have been explored further.

References:

Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M., (2017). Bates' guide to physical
examination and history taking. (Twelfth ed.) Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.

Goolsby, M., & Grubbs, L., (2019). Advanced assessment: Interpreting findings and
formulating differential diagnosis. (Fourth ed.) Philadelphia: F. A. Davis

Rhoads, J., & Petersen, S. W. (2017). Advanced health assessment and diagnostic
reasoning (Third ed.). Sudbury: Jones & Bartlett Learning, LLC.