Week 7 Shadow Health DCE Notes Kimberly Reese Walden University NURS 6512 Dr. Vijayarani Suresh

Week 7 Shadow Health DCE Notes Kimberly Reese Walden University NURS 6512 Dr. Vijayarani Suresh July 18, 2021 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 repo