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Exam (elaborations)

Shadow Health- Brian Foster- Focused Exam: Chest Pain with complete solution

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Shadow Health- Brian Foster- Focused Exam: Chest Pain with complete solution Established chief complaint Ans- Reports chest pain Asked about onset and duration of chest pain Ans- Reports chest pain started about five minutes ago Reports chest pain has been constant since it began Reports sitting in bed when pain began Asked to rate chest pain on a scale Ans- Reports current pain is 6/10 Asked about on characteristics of the pain Ans- Describes pain as tight and uncomfortable Denies crushing pain Denies gnawing or tearing pain Denies burning pain Asked about location of the pain Ans- Reports pain location is in middle of the chest Reports slight pain in left shoulder Denies arm pain Denies back pain Denies jaw pain Denies neck pain Asked about pain triggers Ans- Reports pain is aggravated by movement Asked about stress and anxiety Ans- Reports generally low stress lifestyle Denies history of anxiety Denies history of panic attacks Asked relevant health history Ans- Reports high blood pressure Reports high cholesterol Denies history of pulmonary embolism Denies history of angina Denies history of rheumatic fever Denies history of heart murmur Followed up on high blood pressure treatment Ans- Reports taking high blood pressure medication Reports high blood pressure medication is Lisinopril High blood pressure medication dose is 20mg High blood pressure medication is taken once daily Followed up on high cholesterol treatment Ans- Reports taking high cholesterol medication Reports high cholesterol medication is Atorvastatin (Lipitor) Reports high cholesterol medication dose is 20mg Reports high cholesterol medication is taken once daily Asked history of cardiac tests Ans- Reports recent EKG test Reports annual stress test Asked about results of cardiac tests Ans- Reports belief that EKG was normal Reports belief that stress test was normal Asked about substance use Ans- Denies illicit drug use Denies tobacco use Reports moderate alcohol consumption Followed up on alcohol consumption Ans- Reports drinking only on weekends Reports drinking 2-4 alcoholic drinks per week Reports 2-3 drinks in a single sitting Asked about exercise Ans- Denies having a regular exercise routine Asked about most recent meal Ans- Reports most recent meal was previous night at 8 p.m Reports meal consisted of buffalo wings Asked about typical diet Ans- Reports typical breakfast is granola bar and instant breakfast shake Reports typical lunch is turkey sub Reports typical dinner is grilled meat and vegetables Denies moderating salt intake Asked about review of cardiovascular system Ans- Denies palpitations Denies swelling Denies circulation problems Denies blood clots Denies easy bleeding Denies easy bruising Asked about constitutional health Ans- Denies fever Denies chills Denies fatigue Denies sleep issues Denies recent weight changes Denies night sweats Denies dizziness or lightheadedness Asked about review of respiratory system Ans- Denies cough Denies shortness of breath while lying down Denies blue skin Asked about throat problems Ans- Denies sore throat Denies difficulty swallowing Asked about review of gastrointestinal system Ans- Denies diarrhea Denies constipation Denies flatus Denies bloating Denies heartburn or GERD Reports earlier nausea Denies vomiting

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Uploaded on
May 12, 2022
Number of pages
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Written in
2021/2022
Type
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