NR 509--Chest Pain Assignment Completed Shadow Health -Transcript,subjective,objective,Education & Empathy,Documentaion

9/25/2019 Chest Pain Assignment | Completed | Shadow Health


Chest Pain Assignment Results | Completed
Advanced Health Assessment - Chamberlain - August 2019, NR509-August-2019
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Your Results Turn In Lab Pass




Overview
Transcript
Transcript
Started: Sep 25, 2019 | Patient Exam Time: 104 min
Subjective Data Collection
All Lines (228) Interview Questions (104) Statements (5) Exam Actions (119)
Objective Data Collection
Greet
Education & Empathy
Hi Brian nice to meet you my name is Jessica I'll be your nurse today 09/25/19 6:10 PM
CDT
Documentation

Self-Reflection
Good morning.


Exam Action
Measured vitals 09/25/19 6:10 PM
CDT


Exam Action
Tested blood pressure in left arm with cuff 09/25/19 6:11 PM
CDT


Question
I'm going to start by taking your vital signs 09/25/19 6:11 PM
CDT



Sure.


Exam Action
Tested blood pressure in right arm with cuff 09/25/19 6:12 PM
CDT


Exam Action
Measured vitals 09/25/19 6:12 PM
CDT


Question
Brings you in today 09/25/19 6:12 PM
CDT


I have been having some troubling chest pain in my chest now and
then for the past month.



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,9/25/2019 Chest Pain Assignment | Completed | Shadow Health

I'm sorry to hear that Empathize
09/25/19 6:13 PM
CDT



Thanks. I appreciate that.


Educate
Chest pain can be concerning let's figure out what's going on 09/25/19 6:13 PM
CDT



Good to know. Thank you.


Question
Are you in pain now 09/25/19 6:13 PM
CDT


No, not right now, but when I do it's tight and uncomfortable. I've
experienced it three times this month.


Question
Can you rate the pain when you have it on a scale of 0 to 10 09/25/19 6:14 PM
CDT


I'd say maybe a . . . 5? It's just really uncomfortable . . . like there's
nothing I can do about it. Right now it's like a zero though.


Question
How long does it last 09/25/19 6:14 PM
CDT



I haven't noticed any palpitations.


Question
How long does the pain last 09/25/19 6:14 PM
CDT


When I feel it, it seems to get better over the course of a couple of
minutes or so.


Question
Does anything make the chest pain better 09/25/19 6:14 PM
CDT



I'm not sure. I think lying still seems to help a little.


Question
When did you first start noticing the chest pain 09/25/19 6:15 PM
CDT




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,9/25/2019 Chest Pain Assignment | Completed | Shadow Health

I first noticed it earlier this month. I thought it might just be heartburn
and it passed after a couple of minutes.


Question
How many times have you felt the pain in the past month 09/25/19 6:15 PM
CDT


Well, it has happened three times the past month. It usually goes
away after about a couple of minutes.


Question
Where is the chest pain located exactly 09/25/19 6:16 PM
CDT


When the pain happens, I feel it mostly in the middle of my chest,
over my heart.


Question
Does the pain radiate anywhere 09/25/19 6:16 PM
CDT


The pain doesn't radiate anywhere. It's mostly just right in the middle
of my chest.


Question
Can you describe the characteristics of the chest pain 09/25/19 6:16 PM
CDT


Well, it mostly feels tight and uncomfortable right in the middle of my
chest.


Question
Does anything make the chest pain worse 09/25/19 6:17 PM
CDT


Well, the pain seems to start when I'm doing something physical . . .
the first time it happened while I was doing yard work, and the
second time . . . I had to take the stairs at work because the elevator
broke. Both times it got better if I took a break or sat down to rest.


Question
When is the last time you felt the pain (Clarified to When was the last
09/25/19 6:17 PM
chest pain episode?.)
CDT


That was . . . last weekend. Last Friday evening, I guess. (Clarified to
when the last chest pain episode was.)


Question
What were you doing last Friday evening when you had the chest
09/25/19 6:18 PM
pain (Clarified to What were you doing last Friday evening?.)
CDT




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, 9/25/2019 Chest Pain Assignment | Completed | Shadow Health

I believe last Friday I took the stairs and felt the tightness shortly
afterward. It's usually after yard work or taking the stairs or
something of that nature. [AUDIO COMING SOON] (Clarified to what
I was doing last Friday evening.)


Question
Have you taken any medications to treat the chest pain (Clarified to
09/25/19 6:19 PM
Did you take anything for the chest pain?.)
CDT



No, not yet. (Clarified to if I took any medication for the chest pain.)


Question
How do you treat the chest pain (Clarified to Are you treating the
09/25/19 6:19 PM
pain?.)
CDT


I haven't taken anything for the chest pain yet. (Clarified to if I am
treating the pain.)


Question
Do you experience any shortness of breath with the chest pain 09/25/19 6:20 PM
CDT



I don't have any shortness of breath, just the chest pain.


Question
Do you feel light-headed when you feel the chest pain 09/25/19 6:20 PM
CDT



I haven't felt faint or even lightheaded really.


Question
Do you have any pain in your left arm 09/25/19 6:26 PM
CDT


No, when I am having the chest pain, it's mostly just in middle of my
chest.


Question
Do you have any pain in your shoulder 09/25/19 6:27 PM
CDT



No, the pain hasn't been in my shoulder.


Question
Has the pain been in your neck 09/25/19 6:27 PM
CDT



My neck's been fine.




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