Focused Exam_ Chest Pain _ Documentation _ Shadow Health.

Document: Provider Notes Student Documentation Model Documentation Subjective Brian Forster is a 58 year old Cacausian male presenting with episodic midsternsal chest pain, described as "thightness" 5/10 occuring 3 times over the last month. Currently pt is not experiencing the pain 0/10. Patient experiences pain onset with exertion and it subsides with rest. First episode was while gardening and the second while climbing stairs. Pt denies ratiation back neck jaw pain, no nausea vomiting or aggrivation with movement, belching or gas. Pt denies gasteroenteral problems no diarrea or constipation, last bowel movement this am. PMH inclusicve for hypertension and hypercholesteremia x 1yr. Pt reports annual EEKG and stress testing with no remarkable results. Tyopical diet reviewd, pt reports weekend alcohol consumption "a couple of beers on the weekend". denies tobacco and illicit drug use, Fmaily Hx significant for heart attack on mother's side. Pt. reports: "I have been having some troubling chest pain in m chest now and then for the past month." Experiencing periodi chest pain with exertion such as yard work, as well as with overeating. Points to midsternum as location. Describes pain a "tight and uncomfortable" upon movement or exertion. Mentio an episode upon going up the stairs to bed. Most recent episo was three days ago after eating a large restaurant dinner. Deni radiation. Pain lasts for "a few" minutes and goes away when rests. States "It has never gotten 'really bad'" so he didn't thin was an emergency, but is concerned after three episodes in o month and wants his heart checked out. Last physical was 1 y ago but says he hadn't been checked out for several years pri His regular diet includes grilled meat, some sandwiches, and vegetables. Reports grilling between 4-5 times a week, usually meat. Has fast food for lunch on busy days. 1-2 cups of coffee day. Denies coughing, shortness of breath, indigestion, heartb jaw pain, fatigue, dizziness, weakness, nausea, vomiting, and diarrhea. Denies chest pain at time of interview. No history of anxiety or depression. Your Results Lab Pass (/assignment_attempts//lab_ Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Program Competency Progress Document: Vitals Document: Provider Notes Support This study source was downloaded by from CourseH on :13:37 GMT -05:00 4/11/2021 Focused Exam: Chest Pain | Completed | Shadow Health Student Documentation Model Documentation Objective Pt is alert and oriented x4 able to speak in full sentences sitting on exam table without apparent distress but with mildley elevated HR. Skin warm dry no tenting. CV: Righrt bruit auscultadted and thrill palpates 3+, S1 S2 and S4 noted, HR elevated rugular, ccapilary refil 3sec. PMI displaced laterally 3cm brisk and tapping. ECG regular sinus rhythm no st changes. Respiratory: unlabored breathing, distress or increased work of breathing noted, lung sounds noted in all fields, rales in left and right bases noted. GI: flat soft non tender bowel sounds hyperactive in all quadrants. no masses palpable, liver 1 cm below costal margin , spleen and bilaterall kidneys not palpable • General Survey: Alert and oriented, with clear speech. Sitting comfortably in no acute distress. • Cardiac: S1, S2, without murmurs or rubs. S3 noted at mitra area. No swelling or fluid retention present. • Peripheral Vascular: No JVD present. JVP 3 cm above sterna angle. Left carotid no bruit. Right side carotid bruit. Right caro pulse with thrill, 3+. Brachial, radial, femoral pulses without thr 2+. Popliteal, tibial, and dorsalis pedis pulses without thrill, 1+ Cap refill less than 3 seconds in all 4 extremities. • Respiratory: Breathing is quiet and unlabored. Breath sounds clear to auscultation in upper lobes and RML. Fine crackles in posterior bases of L/R lungs. • Gastrointestinal: Round, soft, non-tender with normoactive bowel sounds in all quadrants; no abdominal bruits. No tenderness to light or deep palpation. Tympanic throughout. L is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. • Neuro: Alert and oriented x 3, follows commands, moves all extremities. Gross cranial nerves 2-12 bilaterally and grossly intact. • Skin: Warm, dry, pink, and intact. No tenting and no sweating • Musculoskeletal: Moves all extremities. • Psych: Normal affect, cooperative, good eye contact. • EKG (interpretation): Regular sinus rhythm. No ST changes. • Gastrointestinal: Round, soft, non-tender with normoactive bowel sounds in 4 quadrants; no abdominal bruits. No tendern to light or deep palpation. Tympanic throughout. Liver is 7 cm the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. • Neuro: Alert and oriented x 3, follows commands, moves all extremities. • Skin: Warm, dry, pink, and intact. No tenting. • EKG (interpretation): Regular