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Shadow health focused chest pain
RN-BSN HOLISTIC HEALTH ASSESSMENT ACROSS THE LIFESPAN (NURS 3315)
The University of Texas at Arlington
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Focused Exam: Chest Pain Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-
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Your Results Lab Pass Lab Pass
Indicates an item that you found. Indicates an item that is available to be found.
Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
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
Overview Subjective Data Collection: 30 of 30 (100%)
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Self-Reflection
Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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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
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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
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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 Denies family history of pulmonary embolism
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Shadow health focused chest pain
Course: RN-BSN HOLISTIC HEALTH ASSESSMENT ACROSS THE LIFESPAN (NURS 3315)
University: The University of Texas at Arlington
