10/11/23, 10:09 AM Documentation - Shadow Health
2/12/2021 PRE-TEST - Focused Exam: Chest Pain (must spend 30 minutes in exam) - due Week 1 | Completed | Shadow Health
PRE-TEST - Focused Exam: Chest Pain (must spend 30 minutes in exam) - due We
1 Results | Completed
Physical Assessment - WCU - January 2021, nurs190-ie_nurs190_202101spi_vr4w
Return to Assignment (/assignments/463506/)
Notice:
The detailed results of your assignment attempt are now available because the Due Date has passed. Your assignment score(s) has not changed.
Your Results Lab Pass (/assignment_attempts/8916007/lab_pass.pd
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Vitals Document: Nursing Notes
Objective Data Collection
Education & Empathy
Document: Nursing Notes
Documentation Student Documentation Model Documentation
Care Plan Subjective
Student Survey Pt reports chest pain started about 5 mins ago
Chest pain is constant
Patient wasa just sitting when the chest pain began
the pain is contant , reports pain of 6/10
describes pain as heavy squeezing pressure right in the middle of
the chest
Patient reports left shoulder hurting a tiny bit
denies neck pain
denies jaw pain
patient denies any stress
reports high blood pressure
reports high cholestorol Mr. Foster is post-op day 3 for a TURP (Transurethral resection o
Denies regular excercise routine prostate). He is complaining of chest pain that began 5 minutes a
Patient only drinks alcohol on weekends 2/3 beers He rates his pain at 6/10. He reports the pain is localized to the s
Patient reports cardiac tests and stress test are normal sternal region and describes it as “squeezing pressure.” He repo
Diet is as follows the pain is constant and increasing in severity. He denies radiatio
typical breakfast is granola bar and instant shake but reports some pressure in the left shoulder as well. He reports
lunch is turkey sub pain was accompanied by nausea at the onset, but denies emes
dinner is grilled meat and vegatables The patient reports becoming increasingly anxious. He denies SO
denies family histroy of stroke and palpitations. He denies tenderness, redness, or changes in
denies history of pulmonary embolism surgical site.
Grandfather died of heart attack on maternal mothers side
denies sleep issues
denies fever
denies chills
denies respiratory issues
reports that he takes lipitor and lisinopril daily
denies crushing pain
denies tearing pain
reports bowel movement this morning
bowel movement was normal.
denies throat issues
2/12/2021 PRE-TEST - Focused Exam: Chest Pain (must spend 30 minutes in exam) - due Week 1 | Completed | Shadow Health
Student Documentation Model Documentation
https://westcoast.shadowhealth.com/assignment_attempts/8916007 1/2
Objective
Appearance no visible abnormal findings
Jugular venous distention 1 cm above sternal angle
chest is symmetric no visible abnormal findings
inspected hands and fingernails no visible abnormal findings
Inspected lower extremities and toenails no visible abnormal findings
Inspected lower extremities for edema no edema present
Tested capillary refill on fingers Less Than 3 seconds
Tested capillary refill on toes Less Than 3 seconds
Palpated carotid arteries right side no thrill 2 + expected
• General Survey: Alert, but uncomfortable appearing middle-age
Palpated corteroid artery left side no thrill 2 + expected
male supine in hospital bed, and mildly diaphoretic. Elevated
Palpated PMI displaced laterally brisk and tapping Less Than 3 cm
respiratory rate and evident distress.
palpated right brachial pulse no thrill 2+
about:blank 1/2
2/12/2021 PRE-TEST - Focused Exam: Chest Pain (must spend 30 minutes in exam) - due Week 1 | Completed | Shadow Health
PRE-TEST - Focused Exam: Chest Pain (must spend 30 minutes in exam) - due We
1 Results | Completed
Physical Assessment - WCU - January 2021, nurs190-ie_nurs190_202101spi_vr4w
Return to Assignment (/assignments/463506/)
Notice:
The detailed results of your assignment attempt are now available because the Due Date has passed. Your assignment score(s) has not changed.
Your Results Lab Pass (/assignment_attempts/8916007/lab_pass.pd
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Vitals Document: Nursing Notes
Objective Data Collection
Education & Empathy
Document: Nursing Notes
Documentation Student Documentation Model Documentation
Care Plan Subjective
Student Survey Pt reports chest pain started about 5 mins ago
Chest pain is constant
Patient wasa just sitting when the chest pain began
the pain is contant , reports pain of 6/10
describes pain as heavy squeezing pressure right in the middle of
the chest
Patient reports left shoulder hurting a tiny bit
denies neck pain
denies jaw pain
patient denies any stress
reports high blood pressure
reports high cholestorol Mr. Foster is post-op day 3 for a TURP (Transurethral resection o
Denies regular excercise routine prostate). He is complaining of chest pain that began 5 minutes a
Patient only drinks alcohol on weekends 2/3 beers He rates his pain at 6/10. He reports the pain is localized to the s
Patient reports cardiac tests and stress test are normal sternal region and describes it as “squeezing pressure.” He repo
Diet is as follows the pain is constant and increasing in severity. He denies radiatio
typical breakfast is granola bar and instant shake but reports some pressure in the left shoulder as well. He reports
lunch is turkey sub pain was accompanied by nausea at the onset, but denies emes
dinner is grilled meat and vegatables The patient reports becoming increasingly anxious. He denies SO
denies family histroy of stroke and palpitations. He denies tenderness, redness, or changes in
denies history of pulmonary embolism surgical site.
Grandfather died of heart attack on maternal mothers side
denies sleep issues
denies fever
denies chills
denies respiratory issues
reports that he takes lipitor and lisinopril daily
denies crushing pain
denies tearing pain
reports bowel movement this morning
bowel movement was normal.
denies throat issues
2/12/2021 PRE-TEST - Focused Exam: Chest Pain (must spend 30 minutes in exam) - due Week 1 | Completed | Shadow Health
Student Documentation Model Documentation
https://westcoast.shadowhealth.com/assignment_attempts/8916007 1/2
Objective
Appearance no visible abnormal findings
Jugular venous distention 1 cm above sternal angle
chest is symmetric no visible abnormal findings
inspected hands and fingernails no visible abnormal findings
Inspected lower extremities and toenails no visible abnormal findings
Inspected lower extremities for edema no edema present
Tested capillary refill on fingers Less Than 3 seconds
Tested capillary refill on toes Less Than 3 seconds
Palpated carotid arteries right side no thrill 2 + expected
• General Survey: Alert, but uncomfortable appearing middle-age
Palpated corteroid artery left side no thrill 2 + expected
male supine in hospital bed, and mildly diaphoretic. Elevated
Palpated PMI displaced laterally brisk and tapping Less Than 3 cm
respiratory rate and evident distress.
palpated right brachial pulse no thrill 2+
about:blank 1/2
