Focused Exam- Chest Pain | SUBJECTIVE

Focused Exam: Chest Pain Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Lab Pass Subjective Data Collection: 30 of 30 (100.0%) ...

Focused Exam: Chest Pain Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Lab Pass Subjective Data Collection: 30 of 30 (100.0%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Indicates an item that you found. Indicates an item that is available to be found. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports sporadic chest pain History of Present Illness Asked about onset of pain Reports chest pain started appearing in the past month Asked about location of pain Reports pain is in center of the chest Reports pain does not radiate Denies arm pain Denies shoulder pain Denies back pain Denies neck pain Asked about duration of pain episodes Reports each episode lasted "several" minutes Asked about frequency of pain Reports 3 episodes in past month Reports that episodes did not seem related Asked about severity of pain Reports current pain is 0 out of 10 Reports pain severity at its worst is 5 out of 10 Asked about character of pain Describes pain as tight and uncomfortable Denies crushing pain Denies gnawing pain Denies burning pain Asked about aggravating factors Reports pain is aggravated by activity Pain occurred with yard work and taking stairs Pain does not worsen with eating Pain does not worsen after spicy foods Pain does not worsen after high-fat foods Asked about relieving factors Reports pain relief with brief period of rest Reports no medication to treat chest pain Medical History Confirmed use of medications Confirms medications Reports taking hypertension medication Reports taking hyperlipidemia medication Reports occasional ibuprofen use Reports taking fish oil Denies aspirin regimen Followed up on hypertension treatment Medication is Lopressor Lopressor dose is 100mg Takes Lopressor once daily Followed up on hyperlipidemia treatment Medication is Lipitor Lipitor dose is 20mg Takes Lipitor once daily Takes Lipitor at bedtime Has taken Lipitor for 1 year Confirmed allergies Confirms allergies (no new allergies reported) Asked about possible contributing factors in health history Reports no known diagnosis of angina Reports hypertension Reports high cholesterol Reports no known coronary artery disease Denies diabetes Denies previous treatment for chest pain Asked about blood pressure monitoring Does not frequently monitor BP at home Reports infrequent BP checks at the doctor or drugstore Reports not remembering typical BP reading Asked about past cardiac tests Reports recent EKG test Reports annual stress test Followed up on results of cardiac tests Reports belief that EKG was normal Reports belief that stress test was normal Asked about visits to healthcare providers Has a primary care provider Reports last visit 3 months ago Usually sees doctor every 6 months Social History Asked about stress Reports generally low stress lifestyle Asked about exercise Denies regular exercise routine Last regular exercising was 2 years ago Asked about typical diet Typical breakfast is granola bar and instant breakfast shake Typical lunch is turkey sub Typical dinner is grilled meat and vegetables Denies moderation of salt intake Asked about liquid intake Reports regular water intake Drinks a liter of water a day Drinks 2 cups of coffee daily Denies soda drinking Asked about substance use Denies current illicit drug use Denies tobacco use Reports moderate alcohol consumption Followed up on alcohol consumption Reports drinking 2-3 alcoholic drinks per week Reports 2-3 drinks in one sitting / night Reports drinking only on weekends Review of Systems Asked about general symptoms Denies fever Denies chills Denies fatigue Denies night sweats Denies weight loss Denies dizziness or lightheadedness Denies palpitations Asked review of systems for cardiovascular Denies history of angina Denies edema Denies circulation problems Denies blood clots Denies history of rheumatic fever Denies history of heart murmur Denies easy bleeding Denies easy bruising Denies cyanosis Asked about review of systems for respiratory Denies cough Denies difficulty breathing Denies orthopnea Asked about review of systems for HEENT Denies change in sense of taste Denies sore throat Denies dysphagia Asked about review of systems for gastrointestinal Denies nausea Denies vomiting Denies diarrhea Denies constipation Denies flatus Denies bloating Denies heartburn or GERD Family History Asked about relevant family history Reports family history of heart attack Denies family history of stroke