Focused Exam: Chest Pain Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Your Results Lab Pass
Overview
Subjective Data Collection: 30 of 30 (100.0%)
Transcript
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Objective Data Collection below to reveal important information,
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Education & Empathy Questions.
Documentation
Self-Reflection Category Scored Items Patient Data
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Experts selected these topics as essential
A combination of open and closed questions
components of a strong, thorough interview
will yield better patient data. The following
with this patient.
details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports sporadic chest pain
History of Present Illness
Asked about onset of pain Reports chest pain started appearing in
the past month
Asked about location of pain Reports pain is in center of the chest
Reports pain does not radiate
Denies arm pain
Denies shoulder pain
Denies back pain
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, 5/22/2018 Focused Exam: Chest Pain
Denies neck pain
Asked about duration of pain episodes Reports each episode lasted "several"
minutes
Asked about frequency of pain Reports 3 episodes in past month
Reports that episodes did not seem
related
Asked about severity of pain Reports current pain is 0 out of 10
Reports pain severity at its worst is 5 out
of 10
Asked about character of pain Describes pain as tight and
uncomfortable
Denies crushing pain
Denies gnawing pain
Denies burning pain
Asked about aggravating factors Reports pain is aggravated by activity
Pain occurred with yard work and taking
stairs
Pain does not worsen with eating
Pain does not worsen after spicy foods
Pain does not worsen after high-fat foods
Asked about relieving factors Reports pain relief with brief period of rest
Reports no medication to treat chest pain
Medical History
Confirmed use of medications Confirms medications
Reports taking hypertension medication
Reports taking hyperlipidemia medication
Reports occasional ibuprofen use
Reports taking fish oil
Denies aspirin regimen
Followed up on hypertension treatment Medication is Lopressor
Lopressor dose is 100mg
Takes Lopressor once
daily
Followed up on hyperlipidemia treatment Medication is Lipitor
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