Chest Pain Physical Assessment Assignment Results | Completed
Advanced Health Assessment - Chamberlain, NR509-October-2018
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Your Results Turn In Lab Pass
m
Overview
Documentation / Electronic Health Record
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Transcript
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eH w
Subjective Data Collection Document: Vitals Document: Provider Notes
o.
Objective Data Collection
rs e
ou urc
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
o
Self-Reflection
aC s
Subjective
vi y re
Pt. reports "I have been having some troubling chest
CC: Chest pain pain in my chest now and then for the past month."
Onset: 1 month Experiencing periodic chest pain with exertion such
Location: Mid chest "over heart" as yard work as well as with overeating. Points to
Duration: 3 tmes over the past month, lasting a midsternum as location. Describes pain as “tight and
ed d
couple of minutes uncomfortable.” Denies radiation. Pain lasts for “a
Characteristics: Sudden onset, tight and few” minutes and goes away when he rests. Most
ar stu
uncomfortable 5/10. Currently no pain. Denies any recent episode was three days ago after eating a
radiation, numbness or tingling. Denies any large restaurant dinner. States “It has never gotten
shortness of breath or diaphoresis. ‘really bad’” so didn’t think it was an emergency, but
Aggravating Factors: physical activity is concerned after three episodes in one month and
sh is
Relieving Factors: rest wants his heart checked out. Reports mild cramping
Treatment: none in legs with activity. Denies shortness of breath,
indigestion, heartburn. Denies chest pain at this
Th
Allergies: time.
Codeine-nausea, vomiting
Denies any environmental or food allergies
Medications:
Metoprolol (Lopressor) 100mg po qd, last dose this
morning
Atorvastatin (Lipitor) 20mg po qhs, last dose 10pm
last night for hyperlipidemia
Omega-3 (Fish oil) 1200mg po bid, last dose this
morning for hyperlipidemia
Ibuprofen 200mg po prn "various aches and pains"
PMHx:
Hypertension- 1 year ago
Hypercholesteremia- 1 year ago
Denies any surgeries
https://www.coursehero.com/file/36094984/Chest-Pain-Physical-Assessment-Assignment-Documentationpdf/
Social Hx:
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results Turn In Lab Pass
m
Overview
Documentation / Electronic Health Record
er as
Transcript
co
eH w
Subjective Data Collection Document: Vitals Document: Provider Notes
o.
Objective Data Collection
rs e
ou urc
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
o
Self-Reflection
aC s
Subjective
vi y re
Pt. reports "I have been having some troubling chest
CC: Chest pain pain in my chest now and then for the past month."
Onset: 1 month Experiencing periodic chest pain with exertion such
Location: Mid chest "over heart" as yard work as well as with overeating. Points to
Duration: 3 tmes over the past month, lasting a midsternum as location. Describes pain as “tight and
ed d
couple of minutes uncomfortable.” Denies radiation. Pain lasts for “a
Characteristics: Sudden onset, tight and few” minutes and goes away when he rests. Most
ar stu
uncomfortable 5/10. Currently no pain. Denies any recent episode was three days ago after eating a
radiation, numbness or tingling. Denies any large restaurant dinner. States “It has never gotten
shortness of breath or diaphoresis. ‘really bad’” so didn’t think it was an emergency, but
Aggravating Factors: physical activity is concerned after three episodes in one month and
sh is
Relieving Factors: rest wants his heart checked out. Reports mild cramping
Treatment: none in legs with activity. Denies shortness of breath,
indigestion, heartburn. Denies chest pain at this
Th
Allergies: time.
Codeine-nausea, vomiting
Denies any environmental or food allergies
Medications:
Metoprolol (Lopressor) 100mg po qd, last dose this
morning
Atorvastatin (Lipitor) 20mg po qhs, last dose 10pm
last night for hyperlipidemia
Omega-3 (Fish oil) 1200mg po bid, last dose this
morning for hyperlipidemia
Ibuprofen 200mg po prn "various aches and pains"
PMHx:
Hypertension- 1 year ago
Hypercholesteremia- 1 year ago
Denies any surgeries
https://www.coursehero.com/file/36094984/Chest-Pain-Physical-Assessment-Assignment-Documentationpdf/
Social Hx:
