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Week 7 Shadow Health DCE Notes
Kimberly Reese
Walden University
NURS 6512
Dr. Vijayarani Suresh
July 18, 2021
This study source was downloaded by 100000866603821 from CourseHero.com on 07-14-2023 07:57:39 GMT -05:00
https://www.coursehero.com/file/104104246/Week-7-Shadow-Health-DCE-Notesdocx/
, 2
Week 7 Shadow Health DCE Notes
Name: Kim Reese
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest
Pain Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): The patient is here today because he has "been having chest pain
off and on recently."
History of Present Illness (HPI):
A 58-year-old Caucasian male comes to the office today because he is experiencing
intermittent chest pains recently and has been experiencing shortness of breath. He states
that "it has been going on for a month, and I get short of breath with it too." He also says
that "it is in the middle of his chest, and it becomes tight. He states it doesn't radiate. He
rates his pain a 0/10 at present but has been 5/10 at times. The patient states that he has
had the pain a few times this month, lasting a few minutes. He reports that it had
happened when he was doing physical labor; however, the one time it was when the
elevator broke down at work, and he had to use the stairs. He states when he has this pain;
he sits down for a few minutes; rest seems to help. He describes the pain as "tight and
uncomfortable." The pain doesn't worsen with eating generally and doesn't present after
eating spicy or high-fat foods. The patient denies cough or shortness of breath at this time.
He denies anxiety, states he "is pretty laid back." He has not tried any medication to
relieve his discomfort.
Medications: Lisinopril 20mg PO Daily, Atorvastatin 20mg PO daily at bedtime, Omega
3 Fish Oil 1200mg PO BID Ibuprofen 400mg as needed for muscle discomfort.
Allergies: Drug Allergy to Codeine, has nausea or vomiting. No latex allergy and states he
does have some environmental allergies. He experiences a "runny nose" at times but
doesn't take medication for it.
Past Medical History (PMH): The patient has a history of high cholesterol and
hypertension and denies any angina or coronary artery disease. He reports he has had a
recent EKG and a stress test that were normal. He denies having diabetes and has not had
any hospitalizations.
Past Surgical History (PSH): He has not had any surgeries
Personal/Social History: The patient states that he does not smoke; however, he endorses
moderate alcohol intake only on weekends. He says he has never used any illegal
substances.
Immunization History: Immunizations up to date. His last tetanus was 10/2014, and he has
had his influenza vaccine this season
This study source was downloaded by 100000866603821 from CourseHero.com on 07-14-2023 07:57:39 GMT -05:00
https://www.coursehero.com/file/104104246/Week-7-Shadow-Health-DCE-Notesdocx/
Week 7 Shadow Health DCE Notes
Kimberly Reese
Walden University
NURS 6512
Dr. Vijayarani Suresh
July 18, 2021
This study source was downloaded by 100000866603821 from CourseHero.com on 07-14-2023 07:57:39 GMT -05:00
https://www.coursehero.com/file/104104246/Week-7-Shadow-Health-DCE-Notesdocx/
, 2
Week 7 Shadow Health DCE Notes
Name: Kim Reese
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest
Pain Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): The patient is here today because he has "been having chest pain
off and on recently."
History of Present Illness (HPI):
A 58-year-old Caucasian male comes to the office today because he is experiencing
intermittent chest pains recently and has been experiencing shortness of breath. He states
that "it has been going on for a month, and I get short of breath with it too." He also says
that "it is in the middle of his chest, and it becomes tight. He states it doesn't radiate. He
rates his pain a 0/10 at present but has been 5/10 at times. The patient states that he has
had the pain a few times this month, lasting a few minutes. He reports that it had
happened when he was doing physical labor; however, the one time it was when the
elevator broke down at work, and he had to use the stairs. He states when he has this pain;
he sits down for a few minutes; rest seems to help. He describes the pain as "tight and
uncomfortable." The pain doesn't worsen with eating generally and doesn't present after
eating spicy or high-fat foods. The patient denies cough or shortness of breath at this time.
He denies anxiety, states he "is pretty laid back." He has not tried any medication to
relieve his discomfort.
Medications: Lisinopril 20mg PO Daily, Atorvastatin 20mg PO daily at bedtime, Omega
3 Fish Oil 1200mg PO BID Ibuprofen 400mg as needed for muscle discomfort.
Allergies: Drug Allergy to Codeine, has nausea or vomiting. No latex allergy and states he
does have some environmental allergies. He experiences a "runny nose" at times but
doesn't take medication for it.
Past Medical History (PMH): The patient has a history of high cholesterol and
hypertension and denies any angina or coronary artery disease. He reports he has had a
recent EKG and a stress test that were normal. He denies having diabetes and has not had
any hospitalizations.
Past Surgical History (PSH): He has not had any surgeries
Personal/Social History: The patient states that he does not smoke; however, he endorses
moderate alcohol intake only on weekends. He says he has never used any illegal
substances.
Immunization History: Immunizations up to date. His last tetanus was 10/2014, and he has
had his influenza vaccine this season
This study source was downloaded by 100000866603821 from CourseHero.com on 07-14-2023 07:57:39 GMT -05:00
https://www.coursehero.com/file/104104246/Week-7-Shadow-Health-DCE-Notesdocx/
