What medical or health concerns are noted in the document?

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Medical and Health Concerns Noted in the Document

The document contains multiple medical and health concerns including musculoskeletal chest pain, respiratory issues, cardiovascular conditions, COVID-19 related concerns, and various symptoms that require clinical evaluation and follow-up.

Musculoskeletal Chest Pain Conditions

  • Costochondritis: Inflammation of one or more ribs and/or cartilages causing musculoskeletal chest pain 1
  • Rib injury: Trauma to one or more ribs resulting in musculoskeletal chest pain 1
  • Slipping rib syndrome: Condition where one or more ribs sublux from the joint causing chest pain 1
  • Sternal injury: Trauma to the sternum causing musculoskeletal chest pain 1
  • Intercostal myofascial injury: Trauma to connective tissues between ribs causing chest pain 1
  • Myositis: Inflammation of muscle tissue causing chest pain 1
  • Enterovirus epidemic myalgia (pleurodynia/Bornholm disease): Infectious myositis causing chest pain 1
  • Psychogenic chest pain: Sensation of musculoskeletal chest pain due to conversion disorder 1
  • Dysfunctional breathing/hyperventilation: Chest pain associated with inappropriate hyperpnea or tachypnea 1
  • Precordial catch syndrome (Texidor's twinge): Brief, sharp chest discomfort associated with inspiration 1

Respiratory Concerns

  • Hypoxemia: Arterial oxygen tension lower than normal range 1
  • Desaturation: Percentage of filled hemoglobin binding sites for oxygen lower than normal 1
  • Dyspnea: Labored breathing 1
  • Tachypnea: Rapid breathing 1
  • Hyperpnea: Deeper breathing than normal 1
  • Stridor: Loud or harsh inspiratory noise associated with upper airway obstruction 1
  • Wheezing: Raspy high-pitched whistling sound on expiration or inspiration associated with lower airway obstruction 1
  • Coughing: Forceful expulsion of air with harsh sound 1
  • Hemoptysis: Coughing up blood from lungs 1

Cardiovascular Concerns

  • Heart failure: Inadequate heart function to meet metabolic needs 1
  • Cardiomegaly: Heart noted to be larger than normal 1
  • Palpitations: Sensation of abnormal heart beating in rate, rhythm, or force 1
  • Irregular heartbeat: Abnormal heart rhythm 1
  • Coronary artery disease risk: Increased risk associated with chronic cough 1
  • Myocarditis: Severe cardiac illness that can occur with COVID-19 1
  • Pericarditis: Inflammation of the pericardium 1
  • Left or right ventricular dysfunction: Cardiac complication that can occur with COVID-19 1

COVID-19 Related Concerns

  • Acute COVID-19 infection: Confirmed, probable, or suspected cases based on testing and symptoms 1
  • Prior COVID-19 infection: With or without residual sequelae 1
  • COVID-19 reinfection: New discrete episode in person with prior history 1
  • Multisystem inflammatory syndrome: Characterized by fever and multiple organ involvement 1

Other Clinical Concerns

  • Epistaxis: Bleeding from the nose 1
  • Poor feeding: Inability to take in normal amounts of food 1
  • Anorexia nervosa: Emotional disorder with obsessive desire to lose weight by refusing to eat 1
  • Failure to thrive: Insufficient weight gain 1
  • Hypercyanotic spell: Profound cyanosis associated with hyperpnea 1
  • Fatigue/lassitude: Extreme tiredness 1
  • Delayed development: Failure to achieve expected mental or physical milestones for age 1
  • Headache: Continuous pain in the head 1
  • Decreased exercise tolerance: Inability to perform increased physical activity compared to normal levels 1
  • Acrocyanosis: Bluish coloration in distal portions of extremities 1
  • Breath-holding spells: Brief involuntary cessation of breathing in response to emotional or painful stimuli 1
  • Ascites: Accumulation of interstitial fluid in peritoneal cavity 1

Ophthalmic Concerns

  • Retinal artery occlusion: Potentially associated with stroke risk and requiring urgent evaluation 1
  • Ophthalmic artery occlusion: May represent initial manifestation of systemic or embolic process 1

Documentation Concerns

  • Incomplete documentation of social and emotional health topics: Research shows these are documented only 30.6% of the time after discussion 2
  • Inconsistent documentation patterns: Varied and fragmented recording methods for health care 3
  • Potential for missing important clinical information: Only 59% of information from patient-physician interactions typically appears in medical records 4

Recommended Follow-up

  • Abnormal findings require further investigation and management 5
  • Comprehensive evaluation of comorbidities for patients with chronic conditions 1
  • Routine vaccinations should be provided as indicated by age 1
  • Thorough diagnostic evaluation for patients with cough to mitigate complications 1

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Specifics in the review of health documentation.

Bratislavske lekarske listy, 2017

Research

The validity of the medical record.

Medical care, 1981

Guideline

Encounter for General Adult Medical Examination with Abnormal Findings

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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