Week 7 Shadow Health DCE Notes
Name: Kim Reese
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain
Documentation
SUBJECTIVE
... [Show More] DATA:
Chief Complaint (CC): The patient is here today because he has "been having chest pain
off and on recently."
History of Present Illness (HPI):
A 58-year-old Caucasian male comes to the office today because he is experiencing
intermittent chest pains recently and has been experiencing shortness of breath. He states
that "it has been going on for a month, and I get short of breath with it too." He also says
that "it is in the middle of his chest, and it becomes tight. He states it doesn't radiate. He
rates his pain a 0/10 at present but has been 5/10 at times. The patient states that he has
had the pain a few times this month, lasting a few minutes. He reports that it had happened
when he was doing physical labor; however, the one time it was when the elevator broke
down at work, and he had to use the stairs. He states when he has this pain; he sits down
for a few minutes; rest seems to help. He describes the pain as "tight and uncomfortable."
The pain doesn't worsen with eating generally and doesn't present after eating spicy or
high-fat foods. The patient denies cough or shortness of breath at this time. He denies
anxiety, states he "is pretty laid back." He has not tried any medication to relieve his
discomfort.
Medications: Lisinopril 20mg PO Daily, Atorvastatin 20mg PO daily at bedtime, Omega 3
Fish Oil 1200mg PO BID Ibuprofen 400mg as needed for muscle discomfort.
Allergies: Drug Allergy to Codeine, has nausea or vomiting. No latex allergy and states he
does have some environmental allergies. He experiences a "runny nose" at times but
doesn't take medication for it.
Past Medical History (PMH): The patient has a history of high cholesterol and
hypertension and denies any angina or coronary artery disease. He reports he has had a
recent EKG and a stress test that were normal. He denies having diabetes and has not had
any hospitalizations.
Past Surgical History (PSH): He has not had any surgeries
Personal/Social History: The patient states that he does not smoke; however, he endorses
moderate alcohol intake only on weekends. He says he has never used any illegal
substances.
Immunization History: Immunizations up to date. His last tetanus was 10/2014, and he has
had his influenza vaccine this season
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Significant Family History: Include a history of parents, grandparents, siblings, and children. The
patient's father died of colon cancer at age 75. He has hypertension and was obese. Mother is 80
years old and has type 2 diabetes and hypertension. Sister is 52 and has type 2 diabetes and
hypertension. Brother died in a car accident at age 24. Maternal grandmother died of breast
cancer at age 65, and paternal grandmother died of pneumonia at age 78. Paternal grandfather
died of "old age" at age 85. He has a son that is 26 that is healthy, and his daughter is 19 and has
asthma.
Review of Systems:
General: Patient states he has had a recent weight gain of 20 pounds. He states he used
to ride a bicycle for exercise until it was stolen a few years ago. He says he watches his diet
but does enjoy a steak sometimes. He denies fever, chills, or night sweats.
Cardiovascular/Peripheral Vascular: The patient denies a history of angina,
edema, or circulation problems. States he hasn't had blood clots, rheumatic fever, or a
history of a heart murmur. He doesn't bleed or bruise easily. He states he doesn't note any
swelling anywhere on his body.
Respiratory: He denies having a recent respiratory illness. He states he has had no
cough, and shortness of breath was with chest pain.
Gastrointestinal: He denies any abdomen pain, states that his bowels move
regularly, and denies nausea or vomiting. He denies heartburn, GERD, or bloating.
Musculoskeletal: He doesn't believe that his chest pain is related to muscle issues.
Psychiatric: The patient denies having anxiety or panic attacks.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Pulse rate 104, blood pressure 140/90, respirations 19, pulse oximeter 98%.
Height 5'11, Weight 197 lbs. BMI 27.5
General: Mr. Foster is a well-developed, well-nourished Caucasian male who is alert and
oriented. He is cooperative and answers all questions appropriately. He appears to be a
good historian.
Cardiovascular/Peripheral Vascular: The patient's color is pink, skin warm and dry. No
JVD distension, S1, S2, and S3 audible. Gallop present. Right carotid 3+ positive for both a bruit
and thrill. Left carotid 2+ without bruit or thrill. Radial, brachial and femoral arteries 2+
amplitude and no thrills noted bilaterally. PMI displaced laterally, brisk and tapping.
Respiratory: No shortness of breath at this time; has fine crackles in posterior bases.
Respirations are easy and unlabored. No cough was noted.
Gastrointestinal: Abdomen is soft, rounded, and non-tender. No present bruit Liver is
palpable, and the spleen is non-palpable.
Musculoskeletal: The patient denies muscle pain in the chest area upon palpation.
Neurological: Alert and oriented x 3, cooperative. Mood and affect are appropriate for the
situation.
Skin: Skin is warm and dry. Nails are blanche well. No skin rashes were noted. [Show Less]