10/11/23, 9:34 AM WK7Assgn 1+Enang+Belinda
Name: Belinda Enang
Section: NURS 6512
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain
Documentation
SUBJECTIVE DATA: Chest pain
Chief Complaint (CC): “I have been having chest pain for over a month now”
History of Present Illness (HPI): Mr. Brian Foster is a 58 years old male Caucasian male who
presented at the emergency department with complaints of chest pain at the mid-sternum of the
chest. It is of acute onset and does not radiate. The pain is tight and uncomfortable, aggravated
by movement up the stairs and exertion. The pain is relieved by rest. He rated the pain a 5 out of
10. The pain is not severe to interfere with the patient`s daily activities. The chest pain is
periodic and lasts a few minutes. He has had three episodes of pain in one month. The last
episode was three days ago. He has not used any medication for his symptoms, he is anxious and
wants to know what the problem is. He denies coughing, shortness of breath, indigestion, fatigue,
dizziness, weakness, nausea, vomiting, heartburn, orthopnea, and syncope.
Medications:
- Lisinopril 20mg PO daily,
- Atorvastatin 20mg PO daily,
- Omega 3 fish oil
Allergies: Codeine (Nausea and vomiting), no other known allergy to environment and food
Past Medical History (PMH): No childhood illness, history of hypertension and hyperlipidemia
Past Surgical History (PSH): No past surgical history
© 2021 Walden University
Sexual/Reproductive History: Sexually active with only his wife
Personal/Social History: Does not use tobacco or illicit drugs. Occasional drinker, says he drinks 2
to 3 cups of beer every weekend. Patient does not exercise at this time, he used to ride a bile in
the past but since the bike has been stolen, he does not do any form of exercise. Breakfast
consists of a granola bar or instant breakfast packet. Sometimes he eats a large breakfast
consisting of egg, potatoes, and beacon. Lunch is typically a turkey sub or salad
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, 10/11/23, 9:34 AM WK7Assgn 1+Enang+Belinda
© 2021 Walden University
Sexual/Reproductive History: Sexually active with only his wife
Personal/Social History: Does not use tobacco or illicit drugs. Occasional drinker, says he drinks 2
to 3 cups of beer every weekend. Patient does not exercise at this time, he used to ride a bile in
the past but since the bike has been stolen, he does not do any form of exercise. Breakfast
consists of a granola bar or instant breakfast packet. Sometimes he eats a large breakfast
consisting of egg, potatoes, and beacon. Lunch is typically a turkey sub or salad
Immunization History: Tdap vaccine 10/24, flu shot this season
Significant Family History:
Father: Hypertension, hyperlipidemia, died of colon cancer at age 75
Mother: Type 2 diabetes and hypertension age 80
Brother: Died in a car accident
Sister: Type 2 diabetes, Hypertension
Maternal Grandmother: Died of breast cancer at age 65
Maternal Grandfather: Died of heart attack
Paternal Grandmother: Died of pneumonia at age 75
Paternal Grandfather: Died of old age at 85
Son: Health age 26
Daughter: Asthma, age 19
Review of Systems
General: Patient reports gaining 15-20 lbs over the las couple of years. Reports
anxiety due to recent chest pain. Denies fever, chills, fatigue, night sweats,
palpitations, dizziness, lightheadedness or syncope.
HEENT: Denies any head traumas, denies vision loss or damage, denies hearing
loss or abnormal discharge, denies nose bleeding or discharge, denies sore throat,
denies any lump or masses
© 2021 Walden University
Cardiovascular/Peripheral Vascular: Reports chest pain intermittently within the last
month, denies current chest pain. Denies palpitations. Denies SOB. Reports past EKG has
been normal (completed 3 months ago), past stress test has been normal (completed last
year). Denies history of rheumatic fever, murmur, edema, or coagulopathy.
Respiratory: Denies history of cough, sputum production, wheezing or shortness
of breath. Denies DOE. Denies pain on deep inspiration. Denies history of chest x-ray.
Reports sleeping with only 1 pillow at night.
about:blank 2/6
Name: Belinda Enang
Section: NURS 6512
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain
Documentation
SUBJECTIVE DATA: Chest pain
Chief Complaint (CC): “I have been having chest pain for over a month now”
History of Present Illness (HPI): Mr. Brian Foster is a 58 years old male Caucasian male who
presented at the emergency department with complaints of chest pain at the mid-sternum of the
chest. It is of acute onset and does not radiate. The pain is tight and uncomfortable, aggravated
by movement up the stairs and exertion. The pain is relieved by rest. He rated the pain a 5 out of
10. The pain is not severe to interfere with the patient`s daily activities. The chest pain is
periodic and lasts a few minutes. He has had three episodes of pain in one month. The last
episode was three days ago. He has not used any medication for his symptoms, he is anxious and
wants to know what the problem is. He denies coughing, shortness of breath, indigestion, fatigue,
dizziness, weakness, nausea, vomiting, heartburn, orthopnea, and syncope.
Medications:
- Lisinopril 20mg PO daily,
- Atorvastatin 20mg PO daily,
- Omega 3 fish oil
Allergies: Codeine (Nausea and vomiting), no other known allergy to environment and food
Past Medical History (PMH): No childhood illness, history of hypertension and hyperlipidemia
Past Surgical History (PSH): No past surgical history
© 2021 Walden University
Sexual/Reproductive History: Sexually active with only his wife
Personal/Social History: Does not use tobacco or illicit drugs. Occasional drinker, says he drinks 2
to 3 cups of beer every weekend. Patient does not exercise at this time, he used to ride a bile in
the past but since the bike has been stolen, he does not do any form of exercise. Breakfast
consists of a granola bar or instant breakfast packet. Sometimes he eats a large breakfast
consisting of egg, potatoes, and beacon. Lunch is typically a turkey sub or salad
about:blank 1/6
, 10/11/23, 9:34 AM WK7Assgn 1+Enang+Belinda
© 2021 Walden University
Sexual/Reproductive History: Sexually active with only his wife
Personal/Social History: Does not use tobacco or illicit drugs. Occasional drinker, says he drinks 2
to 3 cups of beer every weekend. Patient does not exercise at this time, he used to ride a bile in
the past but since the bike has been stolen, he does not do any form of exercise. Breakfast
consists of a granola bar or instant breakfast packet. Sometimes he eats a large breakfast
consisting of egg, potatoes, and beacon. Lunch is typically a turkey sub or salad
Immunization History: Tdap vaccine 10/24, flu shot this season
Significant Family History:
Father: Hypertension, hyperlipidemia, died of colon cancer at age 75
Mother: Type 2 diabetes and hypertension age 80
Brother: Died in a car accident
Sister: Type 2 diabetes, Hypertension
Maternal Grandmother: Died of breast cancer at age 65
Maternal Grandfather: Died of heart attack
Paternal Grandmother: Died of pneumonia at age 75
Paternal Grandfather: Died of old age at 85
Son: Health age 26
Daughter: Asthma, age 19
Review of Systems
General: Patient reports gaining 15-20 lbs over the las couple of years. Reports
anxiety due to recent chest pain. Denies fever, chills, fatigue, night sweats,
palpitations, dizziness, lightheadedness or syncope.
HEENT: Denies any head traumas, denies vision loss or damage, denies hearing
loss or abnormal discharge, denies nose bleeding or discharge, denies sore throat,
denies any lump or masses
© 2021 Walden University
Cardiovascular/Peripheral Vascular: Reports chest pain intermittently within the last
month, denies current chest pain. Denies palpitations. Denies SOB. Reports past EKG has
been normal (completed 3 months ago), past stress test has been normal (completed last
year). Denies history of rheumatic fever, murmur, edema, or coagulopathy.
Respiratory: Denies history of cough, sputum production, wheezing or shortness
of breath. Denies DOE. Denies pain on deep inspiration. Denies history of chest x-ray.
Reports sleeping with only 1 pillow at night.
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