Chest Pain Results

Chest Pain Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

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Chest Pain Results
Chest Pain Results

Transcript

Started: Apr 21, 2020 | Total Time: 113 min

Question 04/21/20 6:58 PM MD

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Your Results Lab Pass (/assignment_attempts/6701636/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

All Lines (238) Interview Questions (87) Statements (30) Exam Actions (121)

Good morning.

What brings you into the clinic today

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

Thanks. I appreciate that.

When did this chest pain start

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

Can you tell me the location of your pain

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

Desert pain radiate to your arm (Clarified to Is your pain radiating?.)

The pain doesn’t radiate anywhere. It’s mostly just right in the middle of my chest. (Clarified to if the pain is radiating.)

Does it radiate to your arm (Clarified to Does the pain travel down your arm?.)

No, my pain doesn’t seem to travel. (Clarified to if the pain travels down my arm.)https://aspen.shadowhealth.com/assignments/313481/https://aspen.shadowhealth.com/site_notice_dismissals?from_flash=true&site_notice_id=419https://www.surveymonkey.com/r/TN9CMB5https://aspen.shadowhealth.com/site_notice_dismissals?from_flash=true&site_notice_id=418https://aspen.shadowhealth.com/assignment_attempts/6701636/lab_pass.pdf

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Do you have shoulder pain with it (No matching questions found.)

Do you have shoulder pain

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

Good to know. Thank you.

Do you have any back pain

I haven’t had back pain, no.

Do you have any neck pain

My neck’s been fine.

How long does it pain happen

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

Does anything happen that causes it to happen (Clarified to Does anything trigger the pain?.)

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. (Clarified to if anything triggers the pain.)

Is there anything that makes it better

Well . . . it seemed to subside a little bit when I sat down to rest for a few minutes.

How frequent is your pain

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

Have you tried any treatment (No matching questions found.)

Have you tried anything to help your pain

This is the first I’m seeing anyone about the pain, so not much has been done yet.

Describe from 0 to 10 Pain Scale (Clarified to How would you rate your chest pain on a scale?.)

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. (Clarified to how I would rate my chest pain on a scale.)

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Can you describe the characteristic of your pain

Light yellow? Yellowish clear? The normal color, I guess.

Can you describe your pain

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

Does it feel like someone standing on your chest

It’s more tight and uncomfortable than anything. I’ve had the feeling . . . maybe three times this month?

Is it a crushing pain

No, it’s more tight and uncomfortable.

Is it a burning pain

Not really.

Is the pain worse when you eat spicy food

I don’t think spicy foods have anything to do with it.

Is the pain worse when you’re eating (Clarified to Does the pain get worse after you eat?.)

I don’t think eating has anything to do with it. One episode did happen when my wife and I were out for dinner, but it seemed to happen before we even settled. The episodes don’t seem all that related, to be honest. (Clarified to if the pain is worse after I eat.)

Are you taking any medication for your pain

I take Ibuprofen for various aches and pains every now and then. That’s about it.

What aches and pains are you having (No matching questions found.)

How often do you get aches and pain

I usually drink water all day at work. At least four glasses, probably more. [AUDIO COMING SOON]

Do you get a chest pain

Well, it doesn’t hurt right now, but I have been having chest pain now and then for the past month.

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Do you have breathing problems

My breathing’s fine.

What is your medical history

The doctors told me I have a little bit of high blood pressure and cholesterol, but that’s it.

Have you had any surgeries

I’ve never had any surgeries.

Are you allergic to any medication

I think I’m allergic to codeine. It makes me toss my cookies.

What happens with codeine (Clarified to What is your reaction to codeine?.)

It makes me nauseous and I vomit. (Clarified to what my reaction to codeine is.)

Have you ever been diagnosed with angina

I’ve never been diagnosed with angina. [AUDIO COMING SOON]

Do you have any coronary heart disease

My grandfather on my mom’s side died of a heart attack. He was in his mid-fifties.

Thanks. I appreciate that.

Do you have diabetes

No, I’ve avoided it but my mother and sister both have it.

High blood pressure

Yes, I supposedly have moderately high blood pressure.

What medication are you taking

Yeah, let’s see, I take atorvastatin for cholesterol, metoprolol for blood pressure. . . Oh yeah, and I take fish oil too. I hear that’s good for your cholesterol. [AUDIO COMING SOON]

Have you ever been admitted for your high blood pressure (Clarified to How do you control your blood pressure?.)

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Well, my healthcare provider started me on metoprolol a year ago to get my blood pressure under control. [AUDIO COMING SOON] (Clarified to how I control my blood pressure.)

Have you been hospitalized for high blood pressure

Yes, I supposedly have moderately high blood pressure.

Do you check your blood pressure daily

I usually only get it checked when I visit the doctor.

What you normal readings are for your BP

Um, let’s see . . . For breakfast I usually eat a granola bar and drink an instant breakfast shake. I’ve been doing that a while since it saves time in the morning. Most days for lunch I get a sandwich from the sub shop near work. That’s usually a turkey sub, but sometimes I get a spicy Italian sub. My wife and I grill a lot, and usually have some grilled meat with veggies for dinner.

Good to know. Thank you.

Good to know. Thank you.

Do you exercise

Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.

Good to know. Thank you.

Have you had any cardiac testing like an EKG

I’ve had . . . well, I guess I’ve had the EKG a few times and they give me an annual stress test.

How are your results (Clarified to What were the results of your heart tests?.)

I’m not sure, all the doctor ever tells me is, “everything looks good.” (Clarified to what the results of my heart tests were.)

Good to know. Thank you.

Are you taking any medication for your cholesterol

I take atorvastatin. [AUDIO COMING SOON]

What is your dosage of all your medications let’s review your medications

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The atorvastatin’s 20 mg a day, and the other one, metoprolol, is 100 mg daily. [AUDIO COMING SOON]

Are you taking any over-the-counter medication

Oh, just ibuprofen or Tylenol occasionally for pain.

Does it help you with your pain

I haven’t taken anything for the chest pain yet.

How much fluid are you drinking a day

I usually drink water all day at work. At least four glasses, probably more. [AUDIO COMING SOON]

Do you drink any caffeine

I drink a cup or two of coffee almost every day. Not much else.

This is make your heart beat fast

No, I haven’t noticed anything like that.

Do you drink any soda

Once in a blue moon maybe. I avoid it 99% of the time.

do you Drink alcohol

Sure, but never more than two or three beers on a weekend.

Do you take illicit drugs

Nope.

Do you smoke cigarettes

Nope, I had a lot of friends who did but I never started.

Do you smoke e-cigarettes

Nope, I had a lot of friends who did but I never started.

Do you have any fever

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I haven’t had a fever, no.

Do you have any chills

I haven’t had chills, no.

Have you had any blood clots or bleeding problems

Not that I know of.

Do you bruise easy

I don’t bruise easily, no.

Do you have circular problems (No matching questions found.)

Deer swimming on your feet (No matching questions found.)

Do you have swelling in your feet

I haven’t noticed any swelling.

Have you had any night sweats

Nope, no night sweats.

Any recent weight loss

Not exactly . . . I’ve gained about fifteen to twenty pounds in the last couple years.

Good to know. Thank you.

Does your heart ever beat fast

No, I haven’t noticed anything like that.

Do you get dizzy or lightheadedness

I haven’t felt faint or even lightheaded really.

Do you have difficulty breathing

My breathing’s fine.

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Have you had a cough

I don’t have a cough.

Do you get any shortness of breath

No, I can usually breathe just fine. Unless I have a cold or something, but that’s rare.

Do you have a change in taste

I can still taste things fine.

Do you have difficulty swallowing

I haven’t had any trouble swallowing.

Germany sore throat

I haven’t had a sore throat in a long time.

Do you have any nausea or vomiting

No, I haven’t felt nauseous. I just had pain in my chest.

Any diarrhea or constipation

I’m not having either of those problems.

Do you get gassy or bloated

No, I wish this was only gas but it feels different.

Do you have any heartburn or GERD

No, I’ve never had problems with heartburn. I sure hope that’s all this is, but it’s pretty intense if it’s heartburn.

Do you have any family history of a heart attack

Well, my mom’s dad died of a heart attack. He was pretty young too.

How old was your grandfather (Clarified to How old was your maternal grandfather when he passed?.)

It’s not a great time to realize this, but he died of a heart attack in his fifties. I think he was 54. (Clarified to how old my maternal grandfather lived to be.)

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Any family history of stroke

No, none that I know of.

Anybody with respiratory problems (Clarified to Do you have a family history of lung problems?.)

Nobody has had anything wrong with their lungs. (Clarified to if I have a family history of lung problems.)

Is there anything that you haven’t told me that I should know

Thankfully, no.

Good to know. Thank you.

Good to know. Thank you.

Good to know. Thank you.

Do you have any headaches right now

No, my head feels okay.

Good to know. Thank you.

Do you feel like your pail (No matching questions found.)

Good to know. Thank you.

Good to know. Thank you.

Im going to look at your abdomen (No matching questions found.)

Good to know. Thank you.

Good to know. Thank you.

Good to know. Thank you.

Good to know. Thank you.

Good to know. Thank you.

Having trouble breathing (Clarified to Are you having difficulty breathing right now?.)

My breathing’s fine. (Clarified to if I am having difficulty breathing now.)

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Good to know. Thank you.

Good to know. Thank you.

I am checking your femoral pulses (No matching questions found.)

Good to know. Thank you.

Good to know. Thank you.

Good to know. Thank you.

Good to know. Thank you.

Good to know. Thank you.

Good to know. Thank you.

Good to know. Thank you.

Good to know. Thank you.

Thanks. I appreciate that.

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