Week 3 – Digital Clinical Experience
Week 3 – Digital Clinical Experience
1.Complete the assignment using the provided template ( see attachment – Week 7_Template)
2. Use the information provided in word documents (3) and PDF documents (3) to complete the assignment – Brian Foster – Documents and transcripts.
3. List your priority diagnosis. For each priority diagnosis, list at least 5 differential diagnoses, each of which must be supported with evidence and guidelines.
4. At least 5 references.
Asked about onset and duration of chest pain
Reports chest pain started about five minutes ago Reports chest pain has been constant since it began Reports sitting in bed when pain began
Asked to rate chest pain on a scale
Reports current pain is 6/10
Asked about on characteristics of the pain
Describes pain as tight and uncomfortable Denies crushing pain Denies gnawing or tearing pain Denies burning pain
Asked about location of the pain
Reports pain location is in middle of the chest Reports slight pain in left shoulder Denies arm pain Denies back pain Denies jaw pain Denies neck pain
Asked about pain triggers
Reports pain is aggravated by movement
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Asked about stress and anxiety
Reports generally low stress lifestyle Denies history of anxiety Denies history of panic attacks
Asked relevant health history
Reports high blood pressure Reports high cholesterol Denies history of pulmonary embolism Denies history of angina Denies history of rheumatic fever Denies history of heart murmur
Followed up on high blood pressure treatment
Reports taking high blood pressure medication Reports high blood pressure medication is Lisinopril High blood pressure medication dose is 20mg High blood pressure medication is taken once daily
Followed up on high cholesterol treatment
Reports taking high cholesterol medication Reports high cholesterol medication is Atorvastatin (Lipitor) Reports high cholesterol medication dose is 20mg Reports high cholesterol medication is taken once daily
Asked history of cardiac tests
Reports recent EKG test Reports annual stress test Week 3 – Digital Clinical Experience
Asked about results of cardiac tests
Reports belief that EKG was normal Reports belief that stress test was normal
Asked about substance use
Denies illicit drug use Denies tobacco use Reports moderate alcohol consumption
Followed up on alcohol consumption
Reports drinking only on weekends Reports drinking 2-4 alcoholic drinks per week Reports 2-3 drinks in a single sitting
Asked about exercise
Denies having a regular exercise routine
Asked about most recent meal
Reports most recent meal was previous night at 8 p.m Reports meal consisted of buffalo wings
Asked about typical diet
Reports typical breakfast is granola bar and instant breakfast shake Reports typical lunch is turkey sub Reports typical dinner is grilled meat and vegetables Denies moderating salt intake
Asked about review of cardiovascular system
Denies palpitations Denies swelling Denies circulation problems Denies blood clots Denies easy bleeding Denies easy bruising
Asked about constitutional health
Denies fever Denies chills Denies fatigue Denies sleep issues Denies recent weight changes Denies night sweats Denies dizziness or lightheadedness
Asked about review of respiratory system
Denies cough Denies shortness of breath while lying down Denies blue skin
Asked about throat problems
Denies sore throat Denies difficulty swallowing
Asked about review of gastrointestinal system
Denies diarrhea Denies constipation Denies flatus Denies bloating Denies heartburn or GERD Reports earlier nausea Denies vomiting
Asked relevant family history
Reports family history of heart attack Denies family history of stroke Denies family history of pulmonary embolism
Established chief complaint
Reports chest pain
Asked about onset and duratio
n of chest pain
Reports chest pain started about five minutes ago
Reports chest pain has been constant since it began
Reports sitting in bed when pain began
Asked to rate chest pain on a scale
Reports current pain is 6/10
Asked about on characteristics of
the pain
Describes pain as tight and uncomfortable
Denies crushing pain
Denies gnawing or tearing pain
Denies burning pain
Asked about location of the pain
Reports pain location is in middle of the chest
Reports slight pain in left shoulder
Denies arm pain
Denies back pain
Denies jaw pain
Denies neck pain
Asked about pain triggers
Reports pain is aggravated by movement
Asked about stress and anxiety
Reports generally low stress lifestyle
Denies history of anxiety
Denies history of panic attacks
Asked relevant health history
Reports high blood pressure
Reports high cholesterol
Denies history of pulmonary embolism
Denies history of angina
Denies history of rheumatic fever
Denies history of heart murmur
Followed up on
high blood pressure treatment
Reports taking high blood pressure medication
Reports high blood pressure medication is Lisinopril
High blood pressure medication dose is 20mg
High blood pressure medication is taken once daily
Followed up on high cholesterol
treatment
Established chief complaint
Reports chest pain
Asked about onset and duration of chest pain
Reports chest pain started about five minutes ago
Reports chest pain has been constant since it began Week 3 – Digital Clinical Experience
Reports sitting in bed when pain began
Asked to rate chest pain on a scale
Reports current pain is 6/10
Asked about on characteristics of the pain
Describes pain as tight and uncomfortable
Denies crushing pain
Denies gnawing or tearing pain
Denies burning pain
Asked about location of the pain
Reports pain location is in middle of the chest
Reports slight pain in left shoulder
Denies arm pain
Denies back pain
Denies jaw pain
Denies neck pain
Asked about pain triggers
Reports pain is aggravated by movement
Asked about stress and anxiety
Reports generally low stress lifestyle
Denies history of anxiety
Denies history of panic attacks
Asked relevant health history
Reports high blood pressure
Reports high cholesterol
Denies history of pulmonary embolism
Denies history of angina
Denies history of rheumatic fever
Denies history of heart murmur
Followed up on high blood pressure treatment
Reports taking high blood pressure medication
Reports high blood pressure medication is Lisinopril
High blood pressure medication dose is 20mg
High blood pressure medication is taken once daily
Followed up on high cholesterol treatment