Focused Exam- Chest Pain | Transcript.pdf - Focused Exam Chest Pain | Completed | Shadow Health Focused Exam Chest Pain Results | Turned In Advanced

Focused Exam- Chest Pain | Transcript.pdf - Focused Exam...

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Unformatted text preview: 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Focused Exam: Chest Pain Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: May 21, 2018 | Patient Exam Time: 185 min All Lines (225) Interview Questions (76) Statements (9) Exam Actions (140) Objective Data Collection Education & Empathy Hello my name is Sara, a student and I will interview today Documentation Self-Reflection Greet 05/21/18 3:22 PM CDT Good morning. Please state your name for me? Question 05/21/18 3:22 PM CDT Brian Robert Foster. And your date of birth? (Clarified to what is the date of your birth.) Question 05/21/18 3:23 PM CDT August 17 . . . [Mr. Foster reports the correct year.] [AUDIO COMING SOON] How old are you? Question 05/21/18 3:23 PM CDT I'm 58 going on 30. What brought you in today? Question 05/21/18 3:24 PM CDT I have been having some troubling chest pain in my chest now and then for the past month. 1/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Measured vitals Exam Action 05/21/18 3:44 PM CDT Tested blood pressure in left arm with cuff Exam Action 05/21/18 3:44 PM CDT Tested blood pressure in right arm with cuff Exam Action 05/21/18 3:44 PM CDT Measured vitals Exam Action 05/21/18 3:44 PM CDT Your chest pain started about a month ago? Question 05/21/18 3:52 PM CDT I first noticed it earlier this month. I thought it might just be heartburn and it passed after a couple of minutes. Describe your chest pain Question 05/21/18 3:55 PM CDT Well, it mostly feels tight and uncomfortable right in the middle of my chest. I'm sorry you're having chest pain Empathize 05/21/18 3:56 PM CDT Thanks. I appreciate that. does the pain radiate? Question 05/21/18 3:57 PM CDT The pain doesn't radiate anywhere. It's mostly just right in the middle of my chest. any arm pain? Question 05/21/18 3:57 PM CDT No, my pain doesn't seem to travel. any shoulder pain? 2/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Question 05/21/18 3:58 PM CDT No, the pain hasn't been in my shoulder. In back pain? (Clarified to do you have back pain.) Question 05/21/18 3:58 PM CDT I haven't had back pain, no. How long does your pain last? Question 05/22/18 1:12 PM CDT When I feel it, it seems to get better over the course of a couple of minutes or so. Sorry to hear that you're having pain Empathize 05/22/18 1:13 PM CDT Thanks. I appreciate that. How often are you having pain? Question 05/22/18 1:13 PM CDT Well, it has happened three times the past month. It usually goes away after about a couple minutes. Is your pain the same every time? Question 05/22/18 1:13 PM CDT It's hard to say. Each time it's happened, the pain has been similar. It's not even pain so much as an uncomfortable feeling in the middle of my chest that lasts a few minutes. How would you rate your pain on a scale of 0 to 10? Question 05/22/18 1:14 PM CDT 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. Does the pain burn? 3/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Question 05/22/18 1:15 PM CDT Not really. Is it a crushing pain? Question 05/22/18 1:15 PM CDT No, it's more tight and uncomfortable. Sorry about that Empathize 05/22/18 1:15 PM CDT Thanks. I appreciate that. What helps your pain? Question 05/22/18 1:17 PM CDT I'm not sure. I think lying still seems to help a little. Are you taking any medications for your chest pain? Question 05/22/18 1:17 PM CDT No, not yet. What are you doing when your chest pain starts? Question 05/22/18 1:18 PM CDT Well, the pain seems to start when I'm doing something physical . . . the first time it happened while I was doing yard work, and the second time . . . I had to take the stairs at work because the elevator broke. Both times it got better if I took a break or sat down to rest. Does the pain get worse when eating? (Clarified to Does eating anything make your pain worse?.) Question 05/22/18 1:20 PM CDT I don't think that has anything to do with it, but I guess I don't know. Do spicy foods give you chest pain? 4/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Question 05/22/18 1:21 PM CDT I don't think spicy foods have anything to do with it. Inspected face Inspected for jugular venous distension: No jugular venous distention; JVP 3 cm above sternal angle Exam Action 05/22/18 1:26 PM CDT Exam Action 05/22/18 1:48 PM CDT Inspected anterior chest wall Exam Action 05/22/18 1:49 PM CDT Inspected left side chest wall Exam Action 05/22/18 1:49 PM CDT Inspected posterior chest wall Exam Action 05/22/18 1:49 PM CDT Inspected right side chest wall Exam Action 05/22/18 1:49 PM CDT Inspected anterior chest wall Exam Action 05/22/18 1:49 PM CDT Inspected left side of abdomen Exam Action 05/22/18 1:50 PM CDT Inspected front of abdomen Exam Action 05/22/18 1:50 PM CDT Inspected right side of abdomen Exam Action 05/22/18 1:50 PM CDT Inspected front of abdomen Exam Action 05/22/18 1:51 PM CDT Inspected left side of abdomen 5/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Exam Action 05/22/18 1:51 PM CDT Inspected front of abdomen Exam Action 05/22/18 1:53 PM CDT Inspected right hand: no visible abnormal findings Exam Action 05/22/18 1:54 PM CDT Inspected left hand: no visible abnormal findings Exam Action 05/22/18 1:54 PM CDT Inspected fingernails of right hand Exam Action 05/22/18 1:54 PM CDT Inspected right hand: no visible abnormal findings Exam Action 05/22/18 1:54 PM CDT Inspected left hand: no visible abnormal findings Exam Action 05/22/18 1:54 PM CDT Inspected fingernails of left hand Exam Action 05/22/18 1:54 PM CDT Inspected right hand: no visible abnormal findings Exam Action 05/22/18 1:54 PM CDT Inspected left hand: no visible abnormal findings Exam Action 05/22/18 1:54 PM CDT Inspected left leg Exam Action 05/22/18 1:55 PM CDT Inspected right leg Exam Action 05/22/18 1:55 PM CDT Inspected toenails on right foot Exam Action 05/22/18 1:55 PM CDT 6/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Inspected left leg Exam Action 05/22/18 1:55 PM CDT Inspected right leg Exam Action 05/22/18 1:55 PM CDT Inspected toenails on left foot Exam Action 05/22/18 1:56 PM CDT Inspected left leg Exam Action 05/22/18 1:56 PM CDT Inspected right leg Exam Action 05/22/18 1:56 PM CDT Inspected right leg for edema: No edema Exam Action 05/22/18 1:58 PM CDT Inspected left leg for edema: No edema Exam Action 05/22/18 1:58 PM CDT Checked capillary refill in fingernails Exam Action 05/22/18 1:58 PM CDT Checked capillary refill in fingernails Exam Action 05/22/18 1:58 PM CDT Checked capillary refill in fingernails Exam Action 05/22/18 1:59 PM CDT Checked capillary refill in fingernails Exam Action 05/22/18 1:59 PM CDT Checked capillary refill in fingernails Exam Action 05/22/18 1:59 PM CDT Checked capillary refill in fingernails Exam Action 05/22/18 1:59 PM CDT 7/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Checked capillary refill in fingernails Exam Action 05/22/18 1:59 PM CDT Checked capillary refill in fingernails Exam Action 05/22/18 1:59 PM CDT Checked capillary refill in toenails Exam Action 05/22/18 2:00 PM CDT Checked capillary refill in toenails Exam Action 05/22/18 2:00 PM CDT Checked capillary refill in toenails Exam Action 05/22/18 2:00 PM CDT Checked capillary refill in toenails Exam Action 05/22/18 2:00 PM CDT Checked capillary refill in toenails Exam Action 05/22/18 2:00 PM CDT Checked capillary refill in toenails Exam Action 05/22/18 2:01 PM CDT Checked capillary refill in toenails Exam Action 05/22/18 2:01 PM CDT Checked capillary refill in toenails Exam Action 05/22/18 2:01 PM CDT Checked capillary refill in toenails Exam Action 05/22/18 2:01 PM CDT Checked capillary refill in toenails Exam Action 05/22/18 2:01 PM CDT Auscultated right carotid pulse: Bruit present Exam Action 05/22/18 2:02 PM CDT 8/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Auscultated left carotid pulse Exam Action 05/22/18 2:02 PM CDT Auscultated right carotid pulse: Bruit present Exam Action 05/22/18 2:02 PM CDT Auscultated aortic area with the bell Exam Action 05/22/18 2:05 PM CDT Auscultated pulmonic area with the bell Exam Action 05/22/18 2:05 PM CDT Auscultated Erb's point with the bell Exam Action 05/22/18 2:05 PM CDT Auscultated tricuspid area with the bell Exam Action 05/22/18 2:05 PM CDT Auscultated mitral area with the bell Exam Action 05/22/18 2:05 PM CDT Auscultated aortic area with the bell Exam Action 05/22/18 2:05 PM CDT Auscultated aortic area with the diaphragm Exam Action 05/22/18 2:05 PM CDT Auscultated mitral area with the diaphragm Exam Action 05/22/18 2:05 PM CDT Auscultated mitral area with the bell Exam Action 05/22/18 2:05 PM CDT Auscultated breath sounds in anterior left lower lobe Exam Action 05/22/18 2:08 PM CDT Auscultated breath sounds in anterior right lower lobe Exam Action 05/22/18 2:08 PM CDT 9/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 05/22/18 2:08 PM CDT Auscultated breath sounds in anterior right middle lobe Exam Action 05/22/18 2:08 PM CDT Auscultated breath sounds in anterior right upper lobe Exam Action 05/22/18 2:08 PM CDT Auscultated breath sounds in anterior left upper lobe Exam Action 05/22/18 2:08 PM CDT Auscultated breath sounds in posterior left upper lobe Exam Action 05/22/18 2:09 PM CDT Auscultated breath sounds in posterior right upper lobe Exam Action 05/22/18 2:09 PM CDT Auscultated breath sounds in posterior right mid-back (lower lobe) Exam Action 05/22/18 2:09 PM CDT Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action 05/22/18 2:09 PM CDT Auscultated breath sounds in posterior left lower lobe Exam Action 05/22/18 2:09 PM CDT Auscultated breath sounds in posterior right lower lobe Exam Action 05/22/18 2:09 PM CDT Auscultated breath sounds in posterior right lower lobe on side Exam Action 05/22/18 2:09 PM CDT Auscultated breath sounds in posterior left lower lobe on side Exam Action 05/22/18 2:09 PM CDT Auscultated aorta in abdomen Exam Action 05/22/18 2:12 PM CDT 10/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Auscultated left renal pulse Exam Action 05/22/18 2:12 PM CDT Auscultated right renal pulse Exam Action 05/22/18 2:13 PM CDT Auscultated right iliac pulse Exam Action 05/22/18 2:13 PM CDT Auscultated left iliac pulse Exam Action 05/22/18 2:13 PM CDT Auscultated left femoral pulse Exam Action 05/22/18 2:13 PM CDT Auscultated right femoral pulse Exam Action 05/22/18 2:13 PM CDT Auscultated left renal pulse Exam Action 05/22/18 2:13 PM CDT Auscultated left iliac pulse Exam Action 05/22/18 2:13 PM CDT Auscultated left femoral pulse Exam Action 05/22/18 2:13 PM CDT Auscultated right femoral pulse Exam Action 05/22/18 2:13 PM CDT Auscultated right iliac pulse Exam Action 05/22/18 2:13 PM CDT Auscultated right renal pulse Exam Action 05/22/18 2:13 PM CDT Auscultated right carotid pulse: Bruit present Exam Action 05/22/18 2:14 PM CDT 11/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Auscultated left carotid pulse Exam Action 05/22/18 2:14 PM CDT Auscultated left upper quadrant Exam Action 05/22/18 2:15 PM CDT Auscultated left lower quadrant Exam Action 05/22/18 2:15 PM CDT Auscultated right upper quadrant Exam Action 05/22/18 2:15 PM CDT Auscultated left upper quadrant Exam Action 05/22/18 2:15 PM CDT Auscultated left lower quadrant Exam Action 05/22/18 2:17 PM CDT Auscultated right lower quadrant Exam Action 05/22/18 2:17 PM CDT Auscultated right upper quadrant Exam Action 05/22/18 2:17 PM CDT Auscultated over spleen Exam Action 05/22/18 2:17 PM CDT Auscultated over liver Exam Action 05/22/18 2:17 PM CDT Palpated left carotid pulse: No thrill, 2+ Exam Action 05/22/18 2:19 PM CDT Palpated right carotid pulse: Thrill, 3+ Exam Action 05/22/18 2:19 PM CDT Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm Exam Action 05/22/18 2:21 PM CDT 12/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Palpated left brachial pulse: No thrill, 2+ Exam Action 05/22/18 2:22 PM CDT Palpated right brachial pulse: No thrill, 2+ Exam Action 05/22/18 2:22 PM CDT Palpated left radial pulse: No thrill, 2+ Exam Action 05/22/18 2:23 PM CDT Palpated right radial pulse: No thrill, 2+ Exam Action 05/22/18 2:23 PM CDT Palpated left femoral pulse: No thrill, 2+ Exam Action 05/22/18 2:24 PM CDT Palpated left femoral pulse: No thrill, 2+ Exam Action 05/22/18 2:25 PM CDT Palpated right femoral pulse: No thrill, 2+ Exam Action 05/22/18 2:25 PM CDT Palpated left popliteal pulse: No thrill, 1+ Exam Action 05/22/18 2:26 PM CDT Palpated right popliteal pulse: No thrill, 1+ Exam Action 05/22/18 2:26 PM CDT Palpated left tibial pulse: No thrill, 1+ Exam Action 05/22/18 2:27 PM CDT Palpated left dorsalis pedis pulse: No thrill, 1+ Exam Action 05/22/18 2:28 PM CDT Palpated right dorsalis pedis pulse: No thrill, 1+ Exam Action 05/22/18 2:28 PM CDT Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/22/18 2:29 PM CDT 13/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/22/18 2:29 PM CDT Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/22/18 2:29 PM CDT Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/22/18 2:29 PM CDT Palpated left upper quadrant with deep pressure: No masses Exam Action 05/22/18 2:31 PM CDT Palpated right upper quadrant with deep pressure: No masses Exam Action 05/22/18 2:31 PM CDT Palpated left lower quadrant with deep pressure: No masses Exam Action 05/22/18 2:32 PM CDT Palpated right lower quadrant: with deep pressure: No masses Exam Action 05/22/18 2:32 PM CDT Palpated liver: Palpable 1 cm below right costal margin Exam Action 05/22/18 2:33 PM CDT Palpated for spleen: Not palpable Exam Action 05/22/18 2:55 PM CDT Palpated for left kidney: Not palpable Exam Action 05/22/18 2:55 PM CDT Palpated for right kidney: Not palpable Exam Action 05/22/18 2:56 PM CDT Tested skin turgor Exam Action 05/22/18 2:57 PM CDT Percussed left upper quadrant Exam Action 05/22/18 2:58 PM CDT 14/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Percussed right upper quadrant Exam Action 05/22/18 2:58 PM CDT Percussed left lower quadrant Exam Action 05/22/18 2:58 PM CDT Percussed right lower quadrant Exam Action 05/22/18 2:58 PM CDT Percussed spleen Exam Action 05/22/18 3:00 PM CDT Percussed spleen Exam Action 05/22/18 3:01 PM CDT Percussed for liver span: 7 cm in the mid-clavicular line Exam Action 05/22/18 3:02 PM CDT Performed EKG Exam Action 05/22/18 3:02 PM CDT Measured vitals Exam Action 05/22/18 3:04 PM CDT Will you confirm the medications you are taking Question 05/22/18 3:04 PM CDT Just codeine. What medications are you taking? Question 05/22/18 3:05 PM CDT Yeah, let's see, I take Lipitor for cholesterol, Lopressor for blood pressure. . . Oh yeah, and I take fish oil too. I hear that's good for your cholesterol. Do you take any aspirin? Question 05/22/18 3:05 PM CDT I usually just take Tylenol or ibuprofen. 15/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health How much ibuprofen? Question 05/22/18 3:05 PM CDT Just a couple when I get a headache, which is not very often. What medication do you take for your high blood pressure? Question 05/22/18 3:07 PM CDT Well, my doctor started me on Lopressor a year ago to get my blood pressure under control. What is the dose of lopressor? Question 05/22/18 3:07 PM CDT I don't have it with me but I'm almost positive it's one hundred milligrams. I take it once a day. It is important to follow the instructions for your medications Educate 05/22/18 3:08 PM CDT Good to know. Thank you. What medication do you take for your high cholesterol? (Clarified to What cholesterol medication do you take?.) Question 05/22/18 3:08 PM CDT I take Lipitor. How much Lipitor do you take? Question 05/22/18 3:08 PM CDT I think it's twenty milligrams a day. How often are you taking it? (Clarified to How frequently are you taking the Lipitor.) Question 05/22/18 3:08 PM CDT I take them daily. I'm pretty good about following the doctor's orders. 16/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Great job on on following doctor's orders Educate 05/22/18 3:09 PM CDT Good to know. Thank you. When do you take your cholesterol medication? (Clarified to how often do you take your high cholesterol medication.) Question 05/22/18 3:09 PM CDT It's 20mg, once a day. When do you take your Lipitor? Question 05/22/18 3:09 PM CDT I usually take it around bedtime. Do you have any new allergies to report? (Clarified to Do you have new allergies.) Question 05/22/18 3:10 PM CDT No. Any part of your medical history think may be contributing to your chest pain? (No matching questions found.) Question 05/22/18 3:13 PM CDT Do you have Angina? Question 05/22/18 3:13 PM CDT I've never been diagnosed with any angina anyway. History of high blood pressure? Question 05/22/18 3:14 PM CDT Yes, I supposedly have moderately high blood pressure. High cholesterol? Question 05/22/18 3:14 PM CDT I think it's up there. I take Lipitor for it. 17/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Any coronary artery disease? Question 05/22/18 3:28 PM CDT Not that I'm aware of. Any previous treatments for chest pain? (No matching questions found.) Question 05/22/18 3:28 PM CDT any treatments for chest pain (Clarified to have you ever had treatments for your chest pain.) Question 05/22/18 3:29 PM CDT This is the first I'm seeing anyone about the pain, so not much has been done yet. diabetes? Question 05/22/18 3:29 PM CDT No, I've avoided it but my mother and sister both have it. Do you monitor your blood pressure? Question 05/22/18 3:32 PM CDT Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it. every had an EKG? (No matching questions found.) Question 05/22/18 3:38 PM CDT any ekg's in the past? (No matching questions found.) Question 05/22/18 3:39 PM CDT Has cardiac test? (Clarified to have you had a heart test.) Question 05/22/18 3:39 PM CDT I've had...well, I guess I've had the EKG a few times and they give me an annual stress test. You seem compliant with all your annual checkups and medications the job Educate 05/22/18 3:39 PM CDT Good to know. Thank you. 18/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health What was your EKG? Question 05/22/18 3:40 PM CDT I don't remember the actual results, but as far as I know, it was normal. When did you last visit your doctor? Question 05/22/18 3:40 PM CDT I had a physical about 3 months ago. I understand Empathize 05/22/18 3:41 PM CDT Thanks. I appreciate that. How often do you see your doctor? Question 05/22/18 3:42 PM CDT I see the doctor every 6 months unless there's something wrong in between. Good job on staying compliant with your doctor Educate 05/22/18 3:42 PM CDT Good to know. Thank you. Do you have any stress? Question 05/22/18 3:42 PM CDT Not usually, but I'm feeling pretty anxious not knowing what's going on with my chest. You exercise? Question 05/22/18 3:43 PM CDT 19/24 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven't had much regular 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. What does your diet consist of? Question 05/22/18 3:44 PM CDT Um let's...
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