Chest Pain

Description

Complete your Focused Exam using the Brian Foster Cough DCE Assignment in Shadow Health. Complete your documentation using the documentation template provided.

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Week 7 – Focused Exam: Chest Pain, Brian Foster – REQUIRED Results | Turned I
Advanced Health Assessment and Diagnostic Reasoning – NP – August 2023, nurs6512-garkfankexr4i4fxd1r758nzalvp9xpgbz3jtsta:canvas-lms-202410
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Your Results
Reopen (/assignment_attempts/15281139/reope
Lab Pass (/assignment_attempts/15281139/lab_pass.
Overview
Transcript
Transcript
Started: Sep 30, 2023 | Total Time: 197 min
Subjective Data Collection
All Lines (167)
Objective Data Collection
Education & Empathy
Interview Questions (78)
Statements (8)
Exam Actions (81)
Hello Brian
09/30/23 8:30 PM
Documentation
Program Competency Progress
Good morning.
What brings you in today
Que
09/30/23 8:31 PM
I have been having some troubling chest pain in my chest now and then for
the past month.
Am so sorry to hear you are in so much pain (No matching questions found.)
Que
09/30/23 8:34 PM
Sorry you feel this pain let see how we can make the pain better (No
matching questions found.)
Que
09/30/23 8:34 PM
Sorry you feel this pain let see how we can make the pain better (No
matching questions found.)
Que
09/30/23 8:34 PM
Sorry you feel this pain let see how we can make the pain better (No
matching questions found.)
Que
09/30/23 8:35 PM
Sorry you feel this pain let see how we can make the pain better (No
matching questions found.)
Que
09/30/23 8:35 PM
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Sorry you feel this pain let see how we can make the pain better (No matching questions found.)
Sorry you feel this pain let see how we can make the pain better (No matching questions found.)
Am sorry you feeling this pain
I’ve been better. I’ve been experiencing this tight, uncomfortable feeling in my chest every now and
then. I’m starting to worry it could be something serious.
When did the pain start
I first noticed it earlier this month. I thought it might just be heartburn and it passed after about a couple
of minutes.
Does it occur before or after eating (No matching questions found.)
Does it occur after eating
I don’t think eating has anything to do with it. One episode did happen when my wife and I were out for
dinner, but it seemed to happen before we even settled. The episodes don’t seem all that related, to be
honest.
Where is the location of the chest pain
When the pain happens, I feel it mostly in the middle of my chest, over my heart.
Can i take a look at your chest (No matching questions found.)
Can i examine your chest area (Clarified to May I listen to your heart?.)
Sure, do what you gotta do. (Clarified to if you can listen to my heart.)
Measured vitals
Tested blood pressure in left arm with cuff
Tested blood pressure in right arm with cuff
Measured vitals
Inspected face
Does the pain goes to your shoulder or back (No matching questions found.)
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Does the pain goes to your shoulder or back (No matching questions found.)
Does the pain spread to other places
The pain doesn’t radiate anywhere. It’s mostly just right in the middle of my chest.
Do have history of back pain (No matching questions found.)
Do have back pain (Clarified to Do you have back pain?.)
I haven’t had back pain, no. (Clarified to if I have back pain.)
How long does the pain last
When I feel it, it seems to get better over the course of a couple of minutes or so.
How many times does the pain happen (Clarified to How many times have you had this chest pain?.)
Well, it has happened three times the past month. It usually goes away after about a couple minutes.
(Clarified to how many times I have had chest pain.)
What is the rate of the pain on a scale of 0-10 (Clarified to Can you rate your current pain level on a
scale of 0 to 10?.)
I’d say maybe a . . . 5? It’s just really uncomfortable . . . like there’s nothing I can do about it. Right now
it’s like a zero though. (Clarified to how I would rate my pain on a scale.)
Can you describe the pain
Well, it mostly feels tight and uncomfortable right in the middle of my chest.
DO you take any medication for the pain
I take Ibuprofen for various aches and pains every now and then. That’s about it.
What relief the pain (Clarified to What relieves your pain?.)
I’m not sure. I think lying still seems to help a little. (Clarified to what relieves the pain.)
Do you have history of blood pressure
Yes, I supposedly have moderately high blood pressure.
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How is your diet
I try to stay conscious of my diet. You know, I watch the fat. I watch the sodium . . . but I’m a dyed-inthe-wool carnivore too. Steaks and burgers find their way in there every once in a while.
Are you on blood pressure medication (Clarified to Do you take blood pressure medication?.)
I take lisinopril, yeah. (Clarified to if I take blood pressure medication.)
Do you check your blood pressure daily
I usually only get it checked when I visit the doctor.
What is the dose of the lisinopril you take
I don’t have it with me but I’m almost positive it’s 20 milligrams. I take it once a day.
It is important you check your blood pressure daily before taking your medication
Good to know. Thank you.
Checking your blood pressure help to know your base line blood pressure and also to monitor the high
blood pressure effectively (No matching questions found.)
Do you have any problem with the heart
I’m a little worried that this chest pain could be a heart problem . . . I do have hypertension, and high
cholesterol. And heart attacks run in my family.
Do you have diabetes
No, I’ve avoided it but my mother and sister both have it.
Do you smoke
Nope, I had a lot of friends who did but I never started.
Do you drink alcohol
Sure, but never more than two or three beers on a weekend.
Do you have any previous chest pain (Clarified to Have you had health problems in the past?.)
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The doctors told me I have a little bit of high blood pressure and cholesterol, but that’s it. (Clarified to if
I have had past health problems.)
Do you have allergies
No, well . . . I’ve had a bad reaction to codeine before, but that is all I know of.
DO you have any food allergies
No, well . . . I’ve had a bad reaction to codeine before, but that is all I know of.
Are you taking any medication for the high cholesterol
I take atorvastatin.
How many mg
Just whatever the bottle recommends for an adult.
Have you had a cardiac test done before
I’ve had . . . well, I had the EKG fairly recently, and I had a stress test at one point. Maybe a little more
than a year ago?
What is the result
I don’t remember. I don’t think it was too bad, though.
Do you take any home medications
Yeah, let’s see, I take atorvastatin for cholesterol, lisinopril for blood pressure. . . Oh yeah, and I take
fish oil too. I hear that’s good for your cholesterol.
Do you know your normal blood pressure
I guess it’s usually somewhat elevated, but no one has ever told me it was bad enough to worry. I’ve
taken lisinopril for about a year now.
Have you seen your PCP about the chest pain
Well, it mostly feels tight and uncomfortable right in the middle of my chest.
Do you exercise
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regula
exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain
I’ve been having.
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What did you eat for breakfast
I didn’t have anything today.
Do you drive
Yeah, I drive. I’m proud to say I’ve never had even the smallest accident.
Do you see your provider regularly (Clarified to Do you see a healthcare provider often?.)
I haven’t been to the doctor in about three months. I usually go every 6 months or so unless something
like this comes up. (Clarified to if I see my healthcare provider often.)
tell me about your typical diet
I try to stay conscious of my diet. You know, I watch the fat. I watch the sodium . . . but I’m a dyed-inthe-wool carnivore too. Steaks and burgers find their way in there every once in a while.
steaks and burger are not good for your health, because they are high in fat
Good to know. Thank you.
tell me about your life activity (Clarified to What is your activity level?.)
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regula
exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain
I’ve been having. (Clarified to what my activity level is.)
Do you drink water frequently
I usually drink water all day at work. At least four glasses, probably more.
do you drink coffee
Maybe 2 cups on weekdays. Sometimes a whole pot on Sunday mornings, but I’ve cut back a lot in the
past few years.
how often do you drink alcohol
I rarely drink during the week. If I drink at all it’s a couple beers on the weekend while I’m grilling or
watching football. Maybe a little bourbon occasionally.
do you have history of drug use (Clarified to Have you abused drugs?.)
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Definitely not. (Clarified to if I have ever abused drugs.)
Do you use any tobacco
No.
Do you have any temperature (Clarified to Do you have a fever?.)
I haven’t had a fever, no. (Clarified to if I have a fever.)
do you have a cold (Clarified to Do you get cold easily?.)
Nope, I haven’t noticed anything. (Clarified to if I get cold easily.)
do you feel tired
No, I don’t feel any more tired than usual.
do you feel shaky
No.
do have medical history of angina
I’ve never been diagnosed with angina.
How is your breathing
I haven’t noticed any breathing problems. I feel like I can breathe just fine.
do you have any cough
I don’t have a cough.
any problem swallowing
I haven’t had any trouble swallowing.
you have any sore throat (Clarified to Do you have throat pain?.)
Nope. (Clarified to if I have throat pain.)
do you have any problem swallowing
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I haven’t had any trouble swallowing.
do you feel bloated
Not really, no.
what the result of the cardiac test
I’m not sure, all the doctor ever tells me is, “everything looks good.”
how often do you drink
I rarely drink during the week. If I drink at all it’s a couple beers on the weekend while I’m grilling or
watching football. Maybe a little bourbon occasionally.
do you feel stress
Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest.
Auscultated right carotid pulse: Bruit present
Auscultated left carotid pulse
Auscultated right carotid pulse: Bruit present
Auscultated left carotid pulse
Auscultated aortic area with the bell
Auscultated pulmonic area with the bell
Auscultated Erb’s point with the bell
Auscultated tricuspid area with the bell
Auscultated Erb’s point with the bell
Auscultated mitral area with the bell
Auscultated tricuspid area with the bell
Auscultated mitral area with the bell
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Auscultated mitral area with the diaphragm
Auscultated tricuspid area with the diaphragm
Auscultated tricuspid area with the bell
Auscultated tricuspid area with the diaphragm
Auscultated breath sounds in anterior right upper lobe
Auscultated breath sounds in anterior left upper lobe
Auscultated breath sounds in anterior right middle lobe
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Auscultated breath sounds in anterior right lower lobe
Auscultated breath sounds in anterior left lower lobe
Auscultated breath sounds in anterior right middle lobe
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Auscultated breath sounds in posterior left upper lobe
Auscultated breath sounds in posterior right upper lobe
Auscultated breath sounds in posterior right mid-back (lower lobe)
Auscultated breath sounds in posterior left lower lobe
Auscultated breath sounds in posterior right lower lobe
Auscultated breath sounds in posterior right lower lobe on side
Auscultated breath sounds in posterior left lower lobe on side
Auscultated breath sounds in posterior right lower lobe on side
Auscultated breath sounds in posterior left lower lobe on side
Auscultated breath sounds in posterior left mid-back (lower lobe)
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Auscultated aorta in abdomen
Auscultated right renal pulse
Auscultated left renal pulse
Auscultated right iliac pulse
Auscultated left iliac pulse
Auscultated right femoral pulse
Auscultated left femoral pulse
Auscultated right upper quadrant
Auscultated left upper quadrant
Auscultated right lower quadrant
Auscultated left lower quadrant
Auscultated over liver
Auscultated over spleen
Palpated right carotid pulse: Thrill, 3+
Palpated left carotid pulse: No thrill, 2+
Palpated left carotid pulse: No thrill, 2+
Palpated left carotid pulse: No thrill, 2+
Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm
Palpated right brachial pulse: No thrill, 2+
Palpated right radial pulse: No thrill, 2+
Palpated left radial pulse: No thrill, 2+
Palpated left radial pulse: No thrill, 2+
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Palpated right femoral pulse: No thrill, 2+
Palpated left femoral pulse: No thrill, 2+
Palpated left femoral pulse: No thrill, 2+
Palpated right popliteal pulse: No thrill, 1+
Palpated left popliteal pulse: No thrill, 1+
Palpated left tibial pulse: No thrill, 1+
Palpated right tibial pulse: No thrill, 1+
Palpated right dorsalis pedis pulse: No thrill, 1+
Palpated left dorsalis pedis pulse: No thrill, 1+
Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or
distension
Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or
distension
Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or
distension
Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or
distension
Percussed right upper quadrant
Percussed left upper quadrant
Percussed right lower quadrant
Percussed left lower quadrant
Percussed spleen
Percussed for liver span: 7 cm in the mid-clavicular line
Performed EKG
Do you exercise
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Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regula
exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain
I’ve been having.
Exercise is good for patient with high blood pressure and cholesterol, we can talk about other type of
exercise that is less strenous for your condition.
Good to know. Thank you.
do you feel stressed
Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest.
Well am sorry you are having the chest pain. It can be uncomfortable and stressful. Am glad you came
so we can find out what is causing the case pain (No matching questions found.)
Well am sorry you are having the chest pain. It can be uncomfortable and stressful. Am glad you came
so we can find out what is causing the case pain
Good to know. Thank you.
how is your weight
I’ve gained maybe 20 pounds over the last couple years. I guess I’m getting older . . . my wife doesn’t
seem to mind though!
Gaining weight over the years is very common. doing moderate exercise and watching your caloric
intake will help maintain your weight.
Good to know. Thank you.
Tell me about your diet (Clarified to What is your diet like?.)
I try to stay conscious of my diet. You know, I watch the fat. I watch the sodium . . . but I’m a dyed-inthe-wool carnivore too. Steaks and burgers find their way in there every once in a while. (Clarified to
what my diet is like.)
Paying attention to your diet is very important.
Good to know. Thank you.
It is best to eat fruits, vegetables, grains, protein, fish and chicken.
Good to know. Thank you.
Tell my about your family history
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Well, my dad died of colon cancer, my mom and sister have diabetes . . . my daughter has asthma, we
all have slightly high blood pressure, my mom’s mom died of breast cancer, and my mom’s dad died of
a heart attack.
Thank you for sharing your family history. It is important to know the history so we help you make
better choices with your health. (No matching questions found.)
Thank you for sharing your family history. It is important to know the history so we help you make
better choices with your health.
Good to know. Thank you.
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
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Week 7 – Focused Exam: Chest Pain, Brian Foster – REQUIRED Results | Turned I
Advanced Health Assessment and Diagnostic Reasoning – NP – August 2023, nurs6512-garkfankexr4i4fxd1r758nzalvp9xpgbz3jtsta:canvas-lms-202410
Return to Assignment (/assignments/873273/)
Your Results
Reopen (/assignment_attempts/15281139/reope
Lab Pass (/assignment_attempts/15281139/lab_pass.
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Program Competency Progress
Document: Vitals
Document: Provider Notes
Document: Vitals
Vitals
Blood Pressure
146/90
O2 Sat
98%
Pulse
104
Resp. Rate
19
Temperature
36.7
Comments
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Privacy Policy (https://www.elsevier.com/legal/privacy-policy)
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10/9/23, 12:42 PM
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(https://support.shadowhealth.com/hc/en-us/articles/360009548313)
Week 7 – Focused Exam: Chest Pain, Brian Foster – REQUIRED Results | Turned I
Advanced Health Assessment and Diagnostic Reasoning – NP – August 2023, nurs6512-garkfankexr4i4fxd1r758nzalvp9xpgbz3jtsta:canvas-lms-202410
Return to Assignment (/assignments/873273/)
Your Results
Reopen (/assignment_attempts/15281139/reope
Lab Pass (/assignment_attempts/15281139/lab_pass.
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Document: Vitals
Document: Provider Notes
Document: Provider Notes
Documentation
Student Documentation
Program Competency Progress
Subjective
Mr. Foster is a 58yrs old caucasain male who present to
the clinin for complains of chest pain for the past month.
Mr. Foster described pain as tight and uncomfortable in
the middle of the chest upon movement and goes away
after few minutes. Patient states pain started 3days ago,
denies pain radiation, describe pain scale as 5/10.
Patient denies coughing, SOB, jaw pain, fatigue,
dizziness, weakness.
Patient denies smoking,
Model Documentation
N/A
Objective
Mr. Foster is a causian white male, alert and oriented x4
with clear speech, follow command with no difficulty,
good eye contact
Moves all extremties
Respiration quiet and unlabored, Lungs sound clear to
ausculatation. Fine crackles heard at the posterior base
of the lungs.
Bowel sound normoactive in all quadrant, no abdominal
bruit, No pain or tenderness to light or deep palpation.
S1,S2 without murmurs or rub, no swelling or fluid
retention noted. S3 noted at mitral area.
Bruit present in Right Carotid artery
Left cartoid artey pulse +2 no thrill.
N/A
Assessment
Based on my assessment on the cardiovascular and
respiratory auscultation abnormal finding indicates
diferential diagnosis of Coronary Artery disease with
stable Angina, CHF, Cartoid disease, GERD
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Student Documentation
Model Documentation
Plan
Mr. Foster will get a 12-lead EKG, chest x-ray, and lab work ( cardiac
enzymes, CBC, BNP, CMP, Lipid panel) to confirm diagnosis.
Recommendation will be given for Stress test, Echocardiogram and cartoid
doppler. Mr. Foster should be prescribed Diltiazam, Duiretic, and ACE
inhibitor in addition to his daily Lisinopril 10mg and Atorvastatin to manage
his hypertension, and nitroglycerin for chest pain that does not subside.
Educate patient on monitoring blood preesure, use of BP machine.
Educate patient on healthy cardiac diet( low sodium, low fat diet), and
walking exercise.
N/A
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
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Name:
Section:
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain
Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): Chest Pain
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough
documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture
of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34year-old AA male). You must include the 7 attributes of each principal symptom:
1.
Location
2.
Quality
3.
Quantity or severity
4.
Timing, including onset, duration, and frequency
5.
Setting in which it occurs
6.
Factors that have aggravated or relieved the symptom
7.
Associated manifestations
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with
dosage and frequency.
Allergies: Codiene.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky
sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and types of operations.
© 2021 Walden University
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of
contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and
IADL’s if applicable, and exercise and eating habits.
Immunization History: Include last Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,
History of Present Illness, and History). Remember that the information you include in this
section is based on what the patient tells you. You will only need to cover systems pertinent to
your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To
ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not
restate HPI data here.
Cardiovascular/Peripheral Vascular:
Respiratory:
Gastrointestinal:
Musculoskeletal:
Psychiatric:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical
exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you
are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry.
© 2021 Walden University
General: Include general state of health, posture, motor activity, and gait. This may also include
dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of
conscience, and affect and reactions to people and things.
Cardiovascular/Peripheral Vascular: Always include the heart in your PE.
Respiratory: Always include this in your PE.
Gastrointestinal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic Test/Labs: Include any labs, x-rays, or other diagnostics that are needed to develop the
differential diagnoses with rationale for each one documented OR ones that were mentioned during
the SH assignment.
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential
diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to
include previous diagnoses and indicate whether these are controlled or not controlled.
© 2021 Walden University

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