Hart City Case Study – Scenario 9 © 2020 Walden Universi

Hart City Case Study – Scenario 9
© 2020 Walden University 1
Program Transcript
MALE SPEAKER: Look who it is. It's little Jimmy.
MALE SPEAKER: Hi, Dan. My name is James, not Jimmy.
MALE SPEAKER: You know, I'm not sure how you were
promoted to the services
coordinator. You never have good ideas. And you're not the best
organized.
To tell you the truth, anyone would have been better than you. I
wouldn't trust you to
supervise paint drying. And they trust you to oversee a unit.
Oh, is little Jimmy getting mad? What are you going to do about
it?
MALE SPEAKER: I am getting really tired of him. He never
quits. The name calling and
insults are really frustrating. How should I handle this?
[MUSIC PLAYING]

Content Attribution
Name: AdobeStockLicense_238412363.jpeg
Credit Line: JackF/ Adobe Stock
Credit Line: Prostock-studio/ Adobe Stock
Document: Provider Notes – NURS 6512
Name:
Focused Exam: Chest Pain
Type your narrative-style documentation for each section of the
assignment into the corresponding dialogue boxes below. When
you are ready to submit your documentation, ‘Save As’ with
this title format: “[LastName_FirstName] Shadow Health
Documentation Template - Focused Exam_Chest_Pain - NURS
6512”
Subjective
Objective
Assessment

- 1 -
Copyright © 2019 || Shadowhealth.com
Name:
Focused Exam: Chest Pain
Subjective
Type your narrative-style documentation for each section of the
assignment into the corresponding dialogue boxes
below. When you are ready to submit your documentation,
‘Save As’ with this title format: “[LastName_FirstName]
Shadow Health Documentation Template - Focused
Exam_Chest_Pain - NURS 6512”
S.
CC: “Chest pain”
HPI: The patient is a 58-year-old white American male who
reports pain in the mid chest every no-and-then
for the past month. The patient states the pain “feels like
tightness than sharp pain” Patient reports pain is in
the middle of the chest over the heart and has occurred three
times in the past month and goes away after a
couple of minutes. Patient rates pain six out of ten in terms of
intensity but is currently a zero intensity. The

pain is aggravated by physical activity and relieved by rest. The
denied taking any medication to relieve the
pain.
PMH: Positive for high blood pressure and high cholesterol,
checks BP during check-up visits to the doctor
every 6months, last labs were drawn 3 months ago. Believes he
takes Lisinopril 20mg daily and Atorvastatin
20mg daily for high BP and high cholesterol, respectively.
Takes 1200mg fish oil daily, Ibuprofen or Tylenol
for pain occasionally, allergy to Codeine causes nausea and
vomiting. Denies previous hospitalizations or
surgeries.
FH: Dad died at 75 from colon cancer but was overweight and
had high blood pressure and high cholesterol
prior to death. Mom is 80 and has type 2 diabetes and high
blood pressure. Brother died from a car accident
at 24 and sister has diabetes and hypertension.
SH: Negative for tobacco or drug use, consumes moderate
amount of alcohol (2 to 3 beers on a weekend),
lives with wife and kids, has “a couple of good friends I can
rely on”, no stress from work. Gained 20 pounds
in the last 2 years, denies regular exercise in the last 2 years,
typical breakfast is instant shakes or granola
bar, lunch is subs or a salad, dinner is grilled meats and
vegetables, drinks at least 4 glasses of water daily.
ROS
General- Anxious about chest pain, denies stress, sleeps 6-7
hours a night, negative for fever, chills, fatigue,
night sweats, dizziness, light-headedness.
Cardiovascular- Denies palpitations, heart murmur, blood clots,
rheumatic fever, bleeding and bruising

easily, reports EKG 3 months ago and stress test yearly with
normal results
Gastrointestinal-Negative for diarrhea, abdominal pain,
constipation, flatus, bloating, heartburn, nausea,
vomiting, indigestion.
Pulmonary- Negative for cough, dyspnea, shortness of breath.
C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m
1
This study source was downloaded by 100000822789681 from
CourseHero.com on 04-15-2021 18:16:01 GMT -05:00
https://www.coursehero.com/file/78222222/Focused-Exam-
Chest-Paindocx/
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Objective
O:
VS: BP 146/90; P 104; R 19; T 36.7; 02 98% Wt 197lbs; Ht 5ft
11 inches
General- Patient appears worried and anxious
Cardiovascular- No jugular vein distention, venous pressure
4cm or less above the sternal angle, chest
symmetrical with no visible abnormalities, capillary refill <3sec
to bilateral fingers and toes, S1, S2 and S3
heart sounds audible with gallops, thrill noted to right carotid

artery with 3+ amplitude, 2+ amplitude and no
thrill other arteries, no bruits to abdominal aorta, or abdominal
or lower extremity arteries, PMI is in the 5th
inter-costal space displaced laterally, brisk and tapping. No
cyanosis, clubbing, noted, no lower extremity
edema is noted.
Gastrointestinal--The abdomen is rounded and symmetrical
without distention; bowel sounds are normal in
quality and intensity in all areas; no tenderness, masses, no
abnormal observations to abdomen, no
abnormality to liver, spleen, kidneys on palpation and
percussion. No tenting.
Pulmonary- Positive lung sounds to all areas bilaterally with
fine crackles noted to bilateral lower lobes.
Diagnostic results: EKG: Normal sinus rhythm with no ST
elevation.
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Assessment

Differential Diagnoses (list a minimum of 3 differential
diagnoses). Your primary or presumptive diagnosis
should be at the top of the list (#1).
Differential Diagnosis:
1) Angina from Coronary artery disease is caused by damage to
the major vessels of the heart usually
from plaque buildup and is characterized by a history of
cardiovascular disease (CVD), it is common
in females ≥65 years or males ≥55 years. In CAD, there could
be no pain or there could be pain that
increases with exercise and the pain is not reproducible by
palpation. The pain in CAD usually has a
duration of 1–60 minutes and is located in the substernal area
(Harskamp et al., 2019). CAD is
high in the list of differential diagnoses because the patient in
this case study is a 58 year old male,
had pain for only a couple of minutes each time, the pain was
not reproducible by palpation, the
patient’s pain was also in the substernal area and was described
as feeling more like “chest
tightness”. All the above and the fact that the patient’s pain also
increased with physical activity and
the patient’s pain has been intermittent makes CAD the primary
diagnosis.
2) Acute coronary syndrome results from the sudden blockage
of coronary artery leading to unstable
angina or myocardial infarction depending on the location of the
blockage and the percentage of the
coronary artery that is blocked. Acute coronary syndrome is
characterized by the radiation of pain,
the presence of nausea/sweating, abnormal EKG, and a history

of coronary artery disease (CAD)
(Harskamp et al., 2019). Acute coronary syndrome is not the
primary diagnosis because the
patient did not have a history of CAD, there was no radiation of
pain and no
nausea/sweating.
Primary Diagnosis/Presumptive Diagnosis: Myocardial
Infarction
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References
Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen,
W., & van Weert, H. (2019). Chest
pain in general practice: a systematic review of prediction rules.
BMJ open, 9(2), e027081.
https://doi.org/10.1136/bmjopen-2018-027081

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Chest-Paindocx/
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Conflict Management Style Orientation Scale
To calculate your score, we grouped the questions according to
5 conflict management styles and totalled the numerical values
of your answers. Higher scores indicate that you are stronger in
that particular style. Within a given style, 15 is the maximum
possible score and 3 is the minimum.
Statements
Totalled
Score
Competing
1, 9, 12
9
Accommodating
2, 7, 11
7
Compromising
3, 6, 15
7
Avoiding
4, 8, 14
7

Collaboration
5, 10, 13
12
© 2020 Walden University 1
Program Transcript
FEMALE SPEAKER: Antoine, can I come in? I have a few
questions.
MALE SPEAKER: Come on in, Stacey. Is everything OK?
FEMALE SPEAKER: Do you remember the service user that I
helped find a job in
spiritual services last week, John?
MALE SPEAKER: Yes, I remember. You did an excellent job
with that case, by the way.
Is something wrong?
FEMALE SPEAKER: I'm not sure. John left me a voicemail
today. He was thanking me
for helping him.
He said that he appreciated my help and that he bought me a
gift. He wants to know a
good time to stop by to give me the gift. I'm honored that John

appreciates my services,
but I'm not sure if I should accept the gift.
MALE SPEAKER: Thank you for coming to me, Stacey. While
there's no specific human
services ethical code that says we should not accept gifts, our
organizational policy
prohibits receiving them. It's best that you notify the service
user so that he understands
the policy. Tell me how you plan to approach the issue with
John.
Program Transcript
Credit Line: Wayhome Studio/ Adobe Stock
Credit Line: ninefotostudio/ Adobe Stock
Credit Line: Wayhome Studio/ Adobe Stock

Hart City Case Study – Scenario 9 © 2020 Walden Universi

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Hart City Case Study – Scenario 9 © 2020 Walden Universi