Focused Exam Chest Pain DOCUMENTATION.pdf

5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health


Focused Exam: Chest Pain Results | Turned In
ii ii ii ii ii ii ii

Advanced ii Health ii Assessment ii- ii Chamberlain, ii NR509-April-2018
Return ii to ii Assignment




Your Results
ii Lab iiPass




Overview
Documentation / Electronic Health ii ii ii


iiTranscrip Record ii



t

Document: iiVitals Document: i i Provider i i Notes
Subjective iiData

iiCollection iiObjective



iiData iiCollection Document: Provider Notes
ii ii



Education ii & ii Empathy Student iiDocumentation Model iiDocumentation
Documentation
iito iialleviate iithe iipain
Subjective
iiwith iia iibrief iirest.
Self-Reflection
iiNot iitaking iiany
Patient iiinformation iiBrian iiFoster iidate iiof iibirth
iimedications iifor
iiAugusti17th, iia ii58 iiyear iiold iiCaucasian iimale
ii chest ii pain. ii Episodes
CC: ii mr. ii Foster ii States" ii I ii have ii been ii having
ii of ii chest ii pain
ii some iitroubling iichest iipain iiin iimy iichest iinow
iistarted iiwith iiphysical
iiand iithen iiforithe iipast iimonth."
iiactivity iiwhile iidoing
HPI:
iiyard iiwork
VS:
b/p ii (L) iiARM ii 146/88 ii mmhg
(R) iiarm ii146/90
iimmhgiMAP

ii109mmhg

HR ii109 iiBPM
RR- ii19
O2 iiSat ii98% iiRA
iiTemp: ii36.7 iiC ii(98

iiF)

Onset iiof iichest iipain iione iimonth iiago, iilasting ii"
iifew iimin" iipt iistates, ii"thought iiit iimay iibe iiheart

iiburn" iireports iiTight iiand iiuncomfortable iiright iiin

iithe iimiddleiof iithe iichest. iiDenies iiany iipain

iiradiating iidenies iiany iiarm iipain iishoulder ii pain

iiback iipain ii or iineck iipain. ii Painionly iilast iia iifew

iiminutes. iiAn iiuncomfortable iifeeling iithat iilasts iia

iifew iiminutes iireporting ii3 iiepisodes iiin iithe iipast

iimonth iiand iiall iifeels iithe iisame. iiPain iicurrently iia

iizero iiwhen iihaving iichest iipain iiis ii5 iiout iiof ii10 iion

iipain iiscale. iiPatient iidescribes iipain iias iitight iiand

iiuncomfortable. iiPatient iidenies iicrushing iior

iiburning iipain iito iithe iichest. iiLaying iidown iiseems

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, 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health



Pt. iireports ii"I iihave iibeen iihaving iisome iitroubling iichest iipain iiin iimy iichest
iinow iiand iithen iifor iithe iipastimonth." iiExperiencing iiperiodic iichest iipain iiwith

iiexertion iisuch iias iiyard iiwork iias iiwell iias iiwith iiovereating. iiPoints iito

iimidsternum iias iilocation.

Describes i i pain ii as i i “tight ii and ii uncomfortable.” iiDenies iiradiation. iiPain iilasts
iifor ii“a iifew” iiminutes iiandigoes ii away i i when i i he i i rests. i i Most i i recent i i episode

i i wasithree iidays iiago iiafter iieating iia iilarge iirestaurant iidinner.iStates ii“It iihas iinever

iigotten ii‘really iibad’” iiso iididn’t iithink iiit iiwas iian iiemergency, iibut iiis iiconcerned

iiafter iithree iiepisodes iiin iione iimonth iiand iiwants iihis iiheart iichecked iiout.

iiReports iimild iicramping iiin iilegs iiwith iiactivity. iiDenies iishortness iiof iibreath,

iiindigestion, iiheartburn. iiDenies iichest iipain iiat iithis iitime.




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https://chamberlain.shadowhealth.com/assignment_attempts/3519143 2/4
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