Shadow health chest pain assessment

Focused Exam: Chest Pain Results | Turned In Advanced Physical Assessment - March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313481/)

(/site_notice_dismissals?from_flash=true&site_noticBecome a paid student tester for Shadow Health! Click here for more information (https://www.surveymonkey.com/r/TN9CMB5)

(/site_notice_dismissals?from_flash=true&site_noticShadow Health will be performing planned maintenance this Friday, from 7:00am until 7:30am Eastern. During this time assignment attempts will be disabled. Thank you for helping us to improve your Shadow Health experience!

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Brain is a 58 you caucasian Male who presents with C/o chest pain in the middle of his chest over his heart, 3 times this month. His pain is 5/10 when the pain arises, no chest pain currently. Chest pain does not radiate to his arm, shoulder or neck. Aggravated chest pain when walking up the steps, and is relieved when he rests. Denies any heartburn, difficult breathing. No change in appetite but mentioned he gained some weight when his bike was stolen. Rare exercise at this moment, desires clearance for exercise since the onset of his chest pain. Never been seen for chest pain, and has not taken anything for chest pain. Medical history: HTN on Lopressor 100 mg/daily x1 year Hyperlipedmia on lipitor 20 mg daily x1 year Omega 3 daily No surgical history Family Medical hx: Father: htn/hyperlipdemia, obesity, died of colon cancer @ 75yo MGF: heart attack died @ 54 yo Sister: HTN and Diabetes type 2 Social hx: beer 3 drinks in a weekend denies tobacco or drug use

Pt. reports "I have been having some troubling chest pain in my chest now and then for the past month." Experiencing periodic c pain with exertion such as yard work as well as with overeating. Points to midsternum as location. Describes pain as “tight and uncomfortable.” Denies radiation. Pain lasts for “a few” minutes goes away when he rests. Most recent episode was three days a after eating a large restaurant dinner. States “It has never gotten ‘really bad’” so didn’t think it was an emergency, but is concerne after three episodes in one month and wants his heart checked o Reports mild cramping in legs with activity. Denies shortness of breath, indigestion, heartburn. Denies chest pain at this time.

Your Results Lab Pass (/assignment_attempts/6701636/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Vitals Document: Provider Notes

https://aspen.shadowhealth.com/assignments/313481/
https://aspen.shadowhealth.com/site_notice_dismissals?from_flash=true&site_notice_id=419
https://www.surveymonkey.com/r/TN9CMB5
https://aspen.shadowhealth.com/site_notice_dismissals?from_flash=true&site_notice_id=418
https://aspen.shadowhealth.com/assignment_attempts/6701636/lab_pass.pdf
Student Documentation Model Documentation

Objective

Brian is a 58 year old Caucasian male appears to be well-groomed, is pleasant and answers questions clearly and appropriately. He maintains eye contact throughout the exam. He appears in no distress VSS: Bp 146/90 Skin warm to touch, dry, pink and intact. no tenting Heart: S1, s2, s3 and S4 with murmur Carotid pulse: positive Thrill, +3 on right: PMI: displaced laterally, briks and tapping, <3cm Breath sounds: clear in upper lobes, posterior lower lobes with crackles bilaterally. GI: no tenderness, no masses, guarding or distension. BS present at all quads, WNL Liver is palpable and nontender: spleen and kidneys are not palpable Extremties: No edema, Brachial and radial pulse neg for thrill at 2+ popliteal, tibal and dorsalis pedis pulse diminised at 1+. capillary refill less than 3 seconds on extremiteis. EKG: Regular sinus rhythm. No ST changes