5/22/2018 Focused Exam: Chest Pain
Focused Exam: Chest Pain Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Your Results Lab Pass
Documentation / Electronic Health Record
Overview
Transcript
Subjective Data Collection Document: Vitals Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation Student Documentation Model Documentation
Self-Reflection
Subjective
Pt. reports "I have been having some troubling
Patient information Brian Foster date of birth
chest pain in my chest now and then for the past
August 17th, a 58 year old Caucasian male
month." Experiencing periodic chest pain with
CC: mr. Foster States" I have been having some
exertion such as yard work as well as with
troubling chest pain in my chest now and then for
overeating. Points to midsternum as location.
the past month."
Describes pain as “tight and uncomfortable.”
HPI:
Denies radiation. Pain lasts for “a few” minutes and
VS:
goes away when he rests. Most recent episode was
b/p (L) ARM 146/88 mmhg three days ago after eating a large restaurant
(R) arm 146/90 mmhg dinner. States “It has never gotten ‘really bad’” so
MAP 109mmhg didn’t think it was an emergency, but is concerned
HR 109 BPM after three episodes in one month and wants his
RR- 19 heart checked out. Reports mild cramping in legs
O2 Sat 98% RA with activity. Denies shortness of breath,
Temp: 36.7 C (98 indigestion, heartburn. Denies chest pain at this
F) time.
Onset of chest pain one month ago, lasting " few
min" pt states, "thought it may be heart burn"
reports Tight and uncomfortable right in the middle
of the chest. Denies any pain radiating denies any
arm pain shoulder pain back pain or neck pain. Pain
only last a few minutes. An uncomfortable feeling
that lasts a few minutes reporting 3 episodes in the
past month and all feels the same. Pain currently a
zero when having chest pain is 5 out of 10 on pain
scale. Patient describes pain as tight and
uncomfortable. Patient denies crushing or burning
pain to the chest. Laying down seems to alleviate
the pain with a brief rest. Not taking any
medications for chest pain. Episodes of chest pain
started with physical activity while doing yard work
1/4
Focused Exam: Chest Pain Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignme
Your Results Lab Pass
Documentation / Electronic Health Record
Overview
Transcript
Subjective Data Collection Document: Vitals Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation Student Documentation Model Documentation
Self-Reflection
Subjective
Pt. reports "I have been having some troubling
Patient information Brian Foster date of birth
chest pain in my chest now and then for the past
August 17th, a 58 year old Caucasian male
month." Experiencing periodic chest pain with
CC: mr. Foster States" I have been having some
exertion such as yard work as well as with
troubling chest pain in my chest now and then for
overeating. Points to midsternum as location.
the past month."
Describes pain as “tight and uncomfortable.”
HPI:
Denies radiation. Pain lasts for “a few” minutes and
VS:
goes away when he rests. Most recent episode was
b/p (L) ARM 146/88 mmhg three days ago after eating a large restaurant
(R) arm 146/90 mmhg dinner. States “It has never gotten ‘really bad’” so
MAP 109mmhg didn’t think it was an emergency, but is concerned
HR 109 BPM after three episodes in one month and wants his
RR- 19 heart checked out. Reports mild cramping in legs
O2 Sat 98% RA with activity. Denies shortness of breath,
Temp: 36.7 C (98 indigestion, heartburn. Denies chest pain at this
F) time.
Onset of chest pain one month ago, lasting " few
min" pt states, "thought it may be heart burn"
reports Tight and uncomfortable right in the middle
of the chest. Denies any pain radiating denies any
arm pain shoulder pain back pain or neck pain. Pain
only last a few minutes. An uncomfortable feeling
that lasts a few minutes reporting 3 episodes in the
past month and all feels the same. Pain currently a
zero when having chest pain is 5 out of 10 on pain
scale. Patient describes pain as tight and
uncomfortable. Patient denies crushing or burning
pain to the chest. Laying down seems to alleviate
the pain with a brief rest. Not taking any
medications for chest pain. Episodes of chest pain
started with physical activity while doing yard work
1/4
