Shadow Health Focused Exams.
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Focused Exam: Chest Pain Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1
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Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
Brain is a 58 you caucasian Male who presents with C/o chest pain in the middle of his chest over his heart, 3 times this month. His pain is 5/10 when the pain arises, no chest pain currently. Chest pain does not radiate to his arm, shoulder or neck. Aggravated chest pain when walking up the steps, and is relieved when he rests. Denies any heartburn, difficult breathing. No change in appetite but mentioned he gained some weight when his bike was stolen. Rare exercise at this moment, desires clearance for exercise since the onset of his chest pain. Never been seen for chest pain, and has not taken anything for chest pain. Medical history: HTN on Lopressor 100 mg/daily x1 year Hyperlipedmia on lipitor 20 mg daily x1 year Omega 3 daily No surgical history Family Medical hx: Father: htn/hyperlipdemia, obesity, died of colon cancer @ 75yo MGF: heart attack died @ 54 yo Sister: HTN and Diabetes type 2 Social hx: beer 3 drinks in a weekend denies tobacco or drug use
Pt. reports “I have been having some troubling chest pain in my chest now and then for the past month.” Experiencing periodic c pain with exertion such as yard work as well as with overeating. Points to midsternum as location. Describes pain as “tight and uncomfortable.” Denies radiation. Pain lasts for “a few” minutes goes away when he rests. Most recent episode was three days a after eating a large restaurant dinner. States “It has never gotten ‘really bad’” so didn’t think it was an emergency, but is concerne after three episodes in one month and wants his heart checked o Reports mild cramping in legs with activity. Denies shortness of breath, indigestion, heartburn. Denies chest pain at this time.
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