NURS 6512: Advanced Health Assessment Week 7 Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
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Course
NURS 6512: Advanced Health Assessment
Institution
NURS 6512: Advanced Health Assessment
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA: intermittent chest pain
Chief Complaint (CC): 58-year-old Caucasian male comes to the clinic complaining of intermittent chest pain that started one month ago. He has had a total of 3 epi...
, Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest
Pain Documentation
SUBJECTIVE DATA: intermittent chest pain
Chief Complaint (CC): 58-year-old Caucasian male comes to the clinic complaining of intermittent chest
pain that started one month ago. He has had a total of 3 episodes within the month. The pain starts
when he is doing physical actives such as yard work or climbing stairs. The patient describes the pain as
“tight and uncomfortable”, rated a 5 out of 10 on the numeric pain scale. Pain resolves after “several
minutes” and relieving factors include laying down flat or resting.
Medications: lisinopril 20mg po daily, atorvastatin 20mg po nightly, occasional Tylenol and ibuprophen
takes “recommended amount”
Allergies: Codeine- Nausea/vomiting
Past Medical History (PMH): hyperlipidemia, hypertension
Past Surgical History (PSH): no surgical history
Sexual/Reproductive History: sexually active with wife
Personal/Social History: occasional alcohol use on the
Immunization History: up to date on all immunizations
Significant Family History: Father: hypertension, hyperlipidemia, obesity, died of colon CA age 75.
Mother: DM2, HTN. Brother: died age 24 from MVA, Sister: DM2, HTN age 52. Maternal grandmother:
died of breast CA age 65. Maternal grandfather: died of heart attack age 54. Paternal grandmother: died
of pneumonia age 78. Paternal grandfather: died 85 from old age. Son: healthy age 26. Daughter:
asthma, age 19.
Review of Systems:
General: no unintentional weight loss, no fatigue or dizziness. afebrile
Cardiovascular/Peripheral Vascular: currently no chest pain, intermittent chest pain is rated 5 out of
10 non-radiating.
Respiratory: no shortness of breath, no dyspnea on exertion
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