NURS 6512 WEEK 7 SHADOW HEALTH DIGITAL CLINICAL EXPERIENCE FOCUSSED EXAM CHEST PAIN ANSWER KEY 2023.

NURS 6512 WEEK 7 SHADOW HEALTH DIGITAL CLINICAL EXPERIENCE FOCUSSED EXAM CHEST PAIN ANSWER KEY 2023. Name: Dana Rice-Smith Section: 6512-11 Week 7 Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation SUBJECTIVE DATA: Include what the patient tells you, but organize the information. Chief Complaint (CC): Chest pain History of Present Illness (HPI) . The patient is a 58-yearl-old white male with onset of chest pain over the past month but at present 0/10 however does report level of pain at times 5/10. The pain description is middle of my chest over my heart, feels tight and uncomfortable. Has had chest pain episodes three times a month lasting a few minutes. Has not taken anything for pain. Exercise or physical activities makes the pain worse. Reports relief if he is lying still helps a little. Denies, chill, sweats, or SOB with chest pain. Denies radiation of pain. 1. Location- Middle of chest 2. Quality-Pressure and tightness 3. Quantity or severity- 5/10 on pain scale 4. Timing, including onset, duration, and frequency- Onset a month ago, lasting a few minutes, three times a month 5. Setting in which it occurs- Occurs at work and home 6. Factors that have aggravated or relieved the symptom- Pain level improves with lying still 7. Associated manifestations- When exercising and walking up a flight of stairs at work Medications: Lisinopril 20 mg qd, atorvastatin 20 mg q hs and Omega-3 fish oil 1200 bid Allergies: Codeine- nausea and vomiting, denies environmental allergies Past Medical History (PMH): HTN stage II diagnosed one year ago, hyperlipidemia, diagnosed a year ago. Had stress test a year ago, reports results were fine. Past Surgical History (PSH): No surgical history lOMoARcPSD| Sexual/Reproductive History: has been monogamous with wife of 27 years however did report STD prior to marriage. Personal/Social History: Denies tobacco use or illicit drugs; drink 2-3 beers on the weekend Immunization History: UTD with immunizations, had covid-19 series Significant Family History: Father: HTN, Hyperlipidemia, obesity, died of colon cancer age 75. Mother: T2DM, HTN, age 80 Sister: T2DM, HTN, age 52 Maternal grandmother: died of breast CA, age 65 Maternal grandfather: died of heart attack, age 54 Paternal grandmother: died of PN, age 78 Paternal grandfather: died of “old age”, age 85 Review of Systems General: Negative fever, chill, sweats; has gain weight 20 over the past few years Cardiovascular/Peripheral Vascular: Negative for orthopnea, reports no edema in BLE. Denies feeling if heart is racing, skipping beats, or feeling flushed. Denies vertigo Respiratory: Positive for SOB with exercise and walking a flight of stair at work; denies cough or hemoptysis Gastrointestinal: Denies chan