NURS 6512 DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): “In the last month, I have occasionally had some unsettling chest
discomfort.”
History of Present Illness (HPI): A 58-year-old Caucasian man named B.F. visits the clinic and
complains of occasional, painful chest pain that has occurred three times in the previous month
but has merely lasted a few minutes on each occasion. The client realized it may have been
heartburn after a short while. He rates his present degree of discomfort as a 0/10, and at his
worst, a 5/10. He says his chest is tight and unpleasant in the center, but he says the discomfort
isn’t radiating. The patient asserts that pain relief occurs when he is resting motionless and is
worse when he is engaging in physical activity, such as raking leaves or climbing stairs.
Additionally, he described experiencing chest pain after eating too much.
- Location-The center of the chest.
- Quality-Tight and unpleasant
- Quantity or severity-0/10 at the present, 5/10 at its worst.
- Timing, including onset, duration, and frequency-started a month ago, lasted a few
minutes, and happened three times.
- Setting in which it occurs- Occurs when going to work and while doing yard chores
at home.
- Factors that have aggravated or relieved the symptom:Pain is lessened by lying
down and increased by exercise.
- Associated manifestations-slight leg cramps when moving around
Medications:
Atorvastatin (Lipitor) 20 mg once a day
Lisinopril (Prinivil) 20 mg once daily
Omega-3 Fish Oil, 1200 mg twice daily taken orally.
As required, Tylenol and Ibuprofen.
Allergies: Codeine – makes him feel sick to his stomach. Denies sensitivities to certain foods or
environments.
Past Medical History (PMH):
Stage II hypertension and hyperlipidemia
Colonoscopy at 50 years old
- Past Surgical History (PSH): neither a recent hospitalization nor a surgical history.
- Sexual/Reproductive History: For the past 27 years, he has only had one sexual relationship
- while married.
- Personal/Social History: The patient works as an engineer. He has been married for 27 years.
- The patient has two children, a daughter, 19, and a son, 26. He says he has a primary care doctor,
- although three months had passed since the last visit. The client denies taking any illicit drugs,
- including cigarettes, cannabis, heroin, cocaine, or any combination thereof. During weekends,
- consumes two to three beers. He used to routinely ride his bike, but not anymore. The doctor
- gave him the go-ahead, and he intends to start exercising. Together with his youngerbrother and
- a friend, the patient likes to go fishing. The client consumes occasional fried meals but mostly
- stays healthy.
- Immunization History:
- 2014 October Tdap.
- Current with flu shots.
- Denies immunization for pneumonia.
- Significant Family History:
- Father: Obese, with high blood pressure and hyperlipidemia, deceased at age 75 from
- colon cancer.
- Mother, 65, suffers from type 2 DM and HTN.
- Sister, 52, suffers from type 2 DM and HTN.
- Brother: Died many years ago in a car accident at the age of 24.
- The daughter, age 19, is asthmatic, and hypertensive.
- Son: 26-year-old, healthy.
- Maternal grandmother: 65 years old; died of breast cancer.
- Maternal grandfather: died at age 54 from a heart attack.
- Paternal grandmother’s death was caused by pneumonia; she was 78 years old.
- The paternal grandfather’s death was attributed to “old age.” Age 85.
- Review of Systems:
- General: The patient is not experiencing sweating or chills. Weight gain of 20
- pounds during the last few years. Denial of exhaustion or stress, no changes in
- appetite.
- HEENT: Normocephalic head with no scars. Eyes: The patient is without
- spectacles. No reported difficulties with the ears. No abnormality was noted in the
- nose. Throat: Nothing unusual has been noted.
- Cardiovascular/Peripheral Vascular: Disavows the presence of edema in the
- lower limbs on eit
