Full Answer Section

Additional information that should be included in the documentation includes the patient’s pain scale score, their level of consciousness, and their mental status. The patient’s activity level and their response to treatment should also be documented.

Is the assessment supported by the subjective and objective information? Why or why not?

The assessment is supported by the subjective and objective information. The patient’s chief complaint of chest pain is consistent with the physical examination findings of chest pain. The patient’s past medical history of heart disease is also consistent with the assessment.

Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?

Yes, diagnostics would be appropriate for this case. The results of diagnostics could be used to confirm the diagnosis of heart disease or to rule out other possible causes of the chest pain.

Some possible diagnostics that could be ordered include an electrocardiogram (EKG), a chest X-ray, and cardiac enzymes. The EKG would show any changes in the heart’s electrical activity that could be indicative of heart disease. The chest X-ray would show any changes in the heart or lungs that could be indicative of heart disease. The cardiac enzymes would show if there is any damage to the heart muscle.

Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

I would accept the current diagnosis of heart disease. The patient’s subjective and objective information are consistent with the diagnosis of heart disease. However, I would also consider three possible differential diagnoses:

• Pleurisy: Pleurisy is an inflammation of the lining of the lungs. It can cause chest pain that is similar to the pain of heart disease. However, pleurisy is typically associated with other symptoms, such as shortness of breath and a cough.
• Gastritis: Gastritis is an inflammation of the lining of the stomach. It can cause chest pain that is similar to the pain of heart disease. However, gastritis is typically associated with other symptoms, such as nausea, vomiting, and heartburn.
• Anxiety: Anxiety can cause chest pain that is similar to the pain of heart disease. However, anxiety is typically associated with other symptoms, such as shortness of breath, palpitations, and a feeling of impending doom.

Here are three references from current evidence-based literature that support my reasoning:

• “Differential Diagnosis of Chest Pain.” UpToDate. UpToDate, 2023. Web. 13 July 2023.
• “Pleurisy.” Mayo Clinic. Mayo Clinic, 2023. Web. 13 July 2023.
• “Gastritis.” National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health, 2023. Web. 13 July 2023.