Clinical Focused SOAP Note For Chest Pain Discussion

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Clinical Focused SOAP Note For Chest Pain Discussion

SUBJECTIVE DATA:

Chief Complaint (CC): chest pain

History of Present Illness (HPI): BF is a 58-year-old Caucasian man who suffers from recurring chest pain that has occurred three times in the last month. The patient reports that the pain is lessened by sitting or laying down and that it worsens with activity. The patient also claims that the discomfort is greater while they are standing or walking. There is a 5/10 degree of discomfort reported by the patient in each episode lasting around 5 minutes. When asked where he feels the pain, the patient says it is “tight and uncomfortable” in the centre of his chest. Denies the existence of pain that is spreading to the arm or back, as well as the neck. Denies having any breathing difficulties. The client is presently denying that he is experiencing any chest pain and rating their level of pain as 0 out of 10. Clinical Focused SOAP Note For Chest Pain Discussion

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Medications:

Lisinopril 20mg daily

Omega-3 Fish Oil 1200mg BID

Atorvastatin 20mg QHS

Allergies:

Codeine- nausea, vomiting,

Past Medical History (PMH):

Hyperlipidemia

Hypertension

Denies history of hospitalizations

Past Surgical History (PSH): Denies surgical history

Sexual/Reproductive History: Identifies as heterosexual and is in a monogamous relationship. Has two children.

Personal/Social History: Denies tobacco or illicit drug use. Reports occasional alcohol use.

Immunization History:

Tdap 10/2014.

Influenza 10/2021.

COVID-19 2021

Significant Family History:

Father- deceased from colon cancer, history of obesity, hypertension, and hyperlipidemia,

Mother – diabetes, Hypertension,

Sister- diabetes, hypertension

Paternal grandmother-died from pneumonia

Maternal grandfather-died from stroke.

Maternal grandmother-died from breast cancer.

Review of Systems:

General: Denies weight change, fatigue , or fever.

Cardiovascular/Peripheral Vascular: Reports pain in the middle of the chest. Denies palpitations or swelling.

Respiratory: Denies wheezing, cough, or shortness of breath.

Gastrointestinal: Denies diarrhea, constipation, vomiting, nausea, or abdominal pain.

Musculoskeletal: Denies muscle pain, or injury. Denies joint pain or injury. Denies history of sprains or fractures.

Psychiatric: Denies history of anxiety, depression or other mental illnesses.

OBJECTIVE DATA: Clinical Focused SOAP Note For Chest Pain Discussion

Physical Exam:

Vital signs: 146/90, P-104, R-19, T-36.7C. Ht- 5’11. Wt 197lbs. BMI 27.5

General: Alert and oriented x 4. Appears well-dressed, well-nourished, and well-groomed. Able to maintain eye contact. Cooperative. Clear and coherent speech

Cardiovascular/Peripheral Vascular: S1, S2, S3 noted with gallops. No murmurs or rubs. PMI displaced laterally at mitral area. Capillary refill less than 3 seconds. EKG-normal sinus rhythm with no ST elevations.

Respiratory: Breath sounds clear to auscultation. Unlabored breathing noted.. Fine crackles in right middle lobe and posterior left lower lobe.

Gastrointestinal: Symmetric, round, soft abdomen, no abnormalities. No abdominal bruits Normoactive bowel sounds. All areas are generally tympanic on percussion. No tenderness to both light and deep palpitation..

Musculoskeletal: 5/5 strength and Full ROM in both extremities.

Neurological: Alert and oriented x 4. Cranial Nerves grossly intact. DTR’s intact

Skin: no visible abnormalities in nails. No cyanosis, skin tenting, or lesion noted

Diagnostic Test/Labs:

EKG- Normal rate and rhythm. No ST elevation.

ASSESSMENT:

Angina Pectoris (Stable Angina): This particular kind of chest pain is brought on by an inadequate supply of blood to the heart. It is a sign that you may be suffering from coronary artery disease. People often use words like “squeezing,” “pressure,” “heaviness,” “tightness,” and “pain” to describe the sensation that they experience in their chests. There is a possibility that it may seem like a big weight is resting on the chest. It’s possible that your angina pectoris is a new discomfort that needs to be checked out by a medical professional, or it might be a reoccurring pain that goes away after you get treatment for it. It is not always easy to differentiate angina pectoris from other forms of chest pain, such as the discomfort caused by indigestion, despite the fact that angina pectoris is rather prevalent (Gillen & Goyal, 2021).

Congestive Heart Failure: This is a condition that manifests itself when the muscle of the heart fails to pump blood as effectively as it should. When anything like this takes place, the body’s blood supply often reverses, and fluid may accumulate in the lungs, leading to a sensation of being unable to catch one’s breath. Certain cardiac disorders, such as restricted arteries in the heart or high blood pressure, can progressively leave the heart unable to fill and pump blood adequately because it will become too weak or stiff (Malike et al, 2021). Symptoms include things like exhaustion, shortness of breath, swelling legs, and a racing pulse.

Coronary Artery Disease: This is a condition that is brought on by a restriction in the blood flow via the coronary arteries, which is often brought on by atheromas. There are a number of clinical symptoms, some of which include silent ischemia, angina pectoris, acute coronary syndromes, and sudden cardiac death. The diagnosis is made based on the patient’s symptoms, as well as the results of an electrocardiogram, stress test, and sometimes, coronary angiography (Shahjehan & Bhutta, 2021)Clinical Focused SOAP Note For Chest Pain Discussion.

References

Gillen, C., & Goyal, A. (2021). Stable Angina. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK559016/

Malik, A., Brito, D., Vaqar, S., & Chhabra, l. (2021). Congestive heart failure. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK430873/

Shahjehan, R.D., & Bhutta, B.S. (2021). Coronary artery disease. StatPearls.

Chest Pain Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations

Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdp, Flu, pneumonia, etc.

Significant Family History: Include history of parents, Grandparents, siblings, and children.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
Cardiovascular/Peripheral Vascular:
Respiratory:
Gastrointestinal:
Musculoskeletal:
Psychiatric:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

Physical Exam: Clinical Focused SOAP Note For Chest Pain Discussion
Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
Cardiovascular/Peripheral Vascular: Always include the heart in your PE.
Respiratory: Always include this in your PE.
Gastrointestinal:
Musculoskeletal:
Neurological:
Skin:

Diagnostic Test/Labs: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses with rationale for each one documented OR ones that were mentioned during the SH assignment.

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.

Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?

In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.

In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
To Prepare
Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
Review the Shadow Health Resources provided in this weekâ€™s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this weekâ€™s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what history would be necessary to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? Clinical Focused SOAP Note For Chest Pain Discussion

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**Below is the transcript to create Soap note.
Hi Mr Foster, My name is , I am going to examine you today.
Greet
10/05/20 1:18 PM MDT

Brian Foster
Good morning.
Your avatar
What brought you here today ?
Question
10/05/20 1:18 PM MDT

Brian Foster
I have been having some troubling chest pain in my chest now and then for the past month.
Your avatar
Oh Iâ€™m sorry to hear that, it should be very uncomfortable to have that pain for a whole month.
Empathize
10/05/20 1:22 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
? (No matching questions found.)
Question
10/05/20 1:22 PM MDT

Your avatar
What is the onset of your pain ?
Question
10/05/20 1:23 PM MDT

Brian Foster
I first noticed it earlier this month. I thought it might just be heartburn and it passed after about a couple of minutes.
Your avatar
What is the exact location of the pain ?
Question
10/05/20 1:24 PM MDT

Brian Foster
When the pain happens, I feel it mostly in the middle of my chest, over my heart.
Your avatar
When did you chest pain start ?
Question
10/05/20 1:25 PM MDT

Brian Foster
I first noticed it earlier this month. I thought it might just be heartburn and it passed after a couple of minutes.NURS6512 Week 7 â€“ Focused Exam: Chest Pain Brian Foster Results
Your avatar
What is the exact location of the pain ?
Question
10/05/20 1:25 PM MDT

Brian Foster
When the pain happens, I feel it mostly in the middle of my chest, over my heart.
Your avatar
Sorry to hear that
Empathize
10/05/20 1:26 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Easter pain radiates anywhere ? (Clarified to Is your pain radiating?.)
Question
10/05/20 1:26 PM MDT

Brian Foster
The pain doesnâ€™t radiate anywhere. Itâ€™s mostly just right in the middle of my chest. (Clarified to if the pain is radiating.)
Your avatar
If your arm hurts (Clarified to Do you have pain in your arm?.)
Question
10/05/20 1:26 PM MDT

Brian Foster
No, when I am having the chest pain, itâ€™s mostly just in middle of my chest. (Clarified to if I have pain in my arm.)
Your avatar
Do you have a pain in your shoulder ?
Question
10/05/20 1:27 PM MDT

Brian Foster
No, the pain hasnâ€™t been in my shoulder.
Your avatar
Do you have a back pain ?
Question
10/05/20 1:27 PM MDT

Brian Foster
I havenâ€™t had back pain, no.
Your avatar
Can you tell me the duration of the pain ? (No matching questions found.)
Question
10/05/20 1:28 PM MDT

Your avatar
Can you describe the duration of the pain ? (Clarified to Can you tell me what the pain is like?.)
Question
10/05/20 1:28 PM MDT

Brian Foster
Well, it mostly feels tight and uncomfortable right in the middle of my chest. (Clarified to if I can tell you what the pain is like.)
Your avatar
How often pain occurs ? (Clarified to How often do you have pain?.)
Question
10/05/20 1:29 PM MDT

Brian Foster
Well, it has happened three times the past month. It usually goes away after about a couple of minutes. (Clarified to how often I have pain.)Clinical Focused SOAP Note For Chest Pain Discussion
Your avatar
Can you describe your pain from 0 to 10 scale ?
Question
10/05/20 1:29 PM MDT

Brian Foster
Iâ€™d say maybe a . . . 5? Itâ€™s just really uncomfortable . . . like thereâ€™s nothing I can do about it. Right now itâ€™s like a zero though.
Your avatar
Sorry to hear that
Empathize
10/05/20 1:30 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Can you describe your pain ?
Question
10/05/20 1:31 PM MDT

Brian Foster
Well, it mostly feels tight and uncomfortable right in the middle of my chest.
Your avatar
ASA pain crashing ? (Clarified to Do you take aspirin?.)
Question
10/05/20 1:31 PM MDT

Brian Foster
I usually just take Tylenol or ibuprofen. (Clarified to if I take aspirin.)
Your avatar
What is the dosage of Tylenol are you taking ?
Question
10/05/20 2:35 PM MDT

Brian Foster
Just whatever the bottle recommends for an adult.
Your avatar
What is the dosage of ibuprofen you taking ? (Clarified to What is the strength of the ibuprofen you take?.)
Question
10/05/20 2:35 PM MDT

Brian Foster
Just whatever the bottle recommends for an adult. (Clarified to What strength ibuprofen I take.)NURS6512 Week 7 â€“ Focused Exam: Chest Pain Brian Foster Results
Your avatar
Is it Tylenol helps ?
Question
10/05/20 2:35 PM MDT

Brian Foster
Just a couple when I get a headache, which is not very often.
Your avatar
How often do you take Tylenol ?
Question
10/05/20 2:36 PM MDT

Brian Foster
I took some today . . . maybe every couple days for mild pain.
Your avatar
What is the reason youâ€™re taking ibuprofen ?
Question
10/05/20 2:36 PM MDT

Brian Foster
Just when I need it for various aches and pains. Probably not more than 3 or 4 times a month.
Your avatar
Where else do you have a pain ?
Question
10/05/20 2:36 PM MDT

Brian Foster
No, when I am having the chest pain, itâ€™s mostly just in middle of my chest.
Your avatar
Do you have a pain somewhere else in your body ?
Question
10/05/20 2:37 PM MDT

Brian Foster
No, when I am having the chest pain, itâ€™s mostly just in middle of my chest.
Your avatar
What is the aggravating factors ? (Clarified to Are there any aggravating factors?.)
Question
10/05/20 2:37 PM MDT

Brian Foster
Well, the pain seems to start when Iâ€™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 there are aggravating factors.)
Your avatar
What activity triggers pain ?
Question
10/05/20 2:39 PM MDT

Brian Foster
If Iâ€™m up and moving around I definitely notice it more and it makes me feel like I should sit down and take a deep breath or something.
Your avatar
Heâ€™s a pain worse when you eat ?
Question
10/05/20 2:40 PM MDT

Brian Foster
I donâ€™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 donâ€™t seem all that related, to be honest.
Your avatar
It can be a lot of triggers in your diet which would aggravate and trigger your pain Mr.Foster.
Educate
10/05/20 2:43 PM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Do you like spicy food ?
Question
10/05/20 2:43 PM MDT

Brian Foster
Sure, I like spicy food. I donâ€™t eat it very often, though. Maybe once or twice a month.
Your avatar
Do you like high-fat food ? (Clarified to Do fatty foods cause the pain?.)Clinical Focused SOAP Note For Chest Pain Discussion
Question
10/05/20 2:44 PM MDT

Brian Foster
I donâ€™t think that has anything to do with it, but I guess I donâ€™t know. (Clarified to if fatty foods cause the pain.)
Your avatar
What relieves your pain ?
Question
10/05/20 2:44 PM MDT

Brian Foster
Iâ€™m not sure. I think lying still seems to help a little.
Your avatar
Take anything for chest pain ?
Question
10/05/20 2:46 PM MDT

Brian Foster
No, not yet.
Your avatar
Do you take medication for hypertension ?
Question
10/05/20 2:46 PM MDT

Brian Foster
I take metoprolol, yes. [AUDIO COMING SOON]
Your avatar
Is a dosage of Metoprolol ? (Clarified to What dose of Lopressor do you take?.)
Question
10/05/20 2:47 PM MDT

Brian Foster
I think itâ€™s 100 mg, once a day. (Clarified to what dose of Lopressor I take.)
Your avatar
Do you take any medication for hyperlipidemia ?
Question
10/05/20 2:47 PM MDT

Brian Foster
I take atorvastatin. [AUDIO COMING SOON]
Your avatar
What is the dosage of atorvastatin are you taking ?
Question
10/05/20 2:48 PM MDT

Brian Foster
I think itâ€™s twenty milligrams a day.
Your avatar
Do you take over-the-counter medications ?
Question
10/05/20 2:48 PM MDT

Brian Foster
Oh, just ibuprofen or Tylenol occasionally for pain.
Your avatar
Do you take any supplements ?
Question
10/05/20 2:48 PM MDT

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Brian Foster
I take fish oil, thatâ€™s it.
Your avatar
How frequently you take medication for hyperlipidemia ? (Clarified to Do you take cholesterol medication?.)
Question
10/05/20 2:49 PM MDT

Brian Foster
I take atorvastatin. [AUDIO COMING SOON] (Clarified to if I take cholesterol medication.)NURS6512 Week 7 â€“ Focused Exam: Chest Pain Brian Foster Results
Your avatar
How often do you take atorvastatin ?
Question
10/05/20 2:50 PM MDT

Brian Foster
I take them daily. Iâ€™m pretty good about following the doctorâ€™s orders.
Your avatar
When have you been diagnosed with high blood pressure ?
Question
10/05/20 2:51 PM MDT

Brian Foster
Yes, I supposedly have moderately high blood pressure.
Your avatar
When you started to take metoprolol ?
Question
10/05/20 2:51 PM MDT

Brian Foster
I think itâ€™s been about one year.
Your avatar
When have you been diagnosed with hyperlipidemia ? (Clarified to Do you have an anxiety disorder?.)
Question
10/05/20 2:51 PM MDT

Brian Foster
Iâ€™ve never had any anxiety problems before. [AUDIO COMING SOON] (Clarified to if I have an anxiety disorder.)
Your avatar
When have you been diagnosed with hyperlipidemia ? (Clarified to Are you diagnosed with high blood pressure?.)
Question
10/05/20 2:52 PM MDT

Brian Foster
Yes, I supposedly have moderately high blood pressure. (Clarified to if I have been diagnosed with hypertension.)
Your avatar
Iâ€™m sorry to hear that
Empathize
10/05/20 2:52 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Do you do exercise ?
Question
10/05/20 2:53 PM MDT

Brian Foster
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I havenâ€™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 Iâ€™ve been having.
Your avatar
Iâ€™m sorry to hear that your bike was stolen
Empathize
10/05/20 2:53 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
When did the exercise last time ?
Question
10/05/20 2:53 PM MDT

Brian Foster
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I havenâ€™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 Iâ€™ve been having.
Your avatar
What type of food do you like ?
Question
10/05/20 2:54 PM MDT

Brian Foster
Um, letâ€™s see . . . For breakfast I usually eat a granola bar and drink an instant breakfast shake. Iâ€™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. Thatâ€™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.
Your avatar
United include a lot of processed and fast food which is not good for your body. To have the same fast food diet may affect you over the time. You need to change your diet.NURS6512 Week 7 â€“ Focused Exam: Chest Pain Brian Foster Results
Educate
10/05/20 2:57 PM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You need to exercise.Not essential to do that with a bike. You can do sit ups, running or just simple indoor exercises in your home.
Educate
10/05/20 2:59 PM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Did you lose any weight ? (Clarified to Have you lost weight?.)
Question
10/05/20 2:59 PM MDT

Brian Foster
Not exactly . . . Iâ€™ve gained about fifteen to twenty pounds in the last couple years. (Clarified to if I have lost weight.)
Your avatar
Itâ€™s not good to gain the weight. You need to change the diet and start doing the exercises. Clinical Focused SOAP Note For Chest Pain Discussion
Educate
10/05/20 3:10 PM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Whatâ€™s whatâ€™s your fathers health ?
Question
10/05/20 3:14 PM MDT

Brian Foster
He really wasnâ€™t doing so great in the last few years. He died when he was 75 of colon cancer, but even before that, his weight and his blood pressure and cholesterol were getting the best of him. It was rough. He didnâ€™t last too long after the cancer diagnosis, unfortunately. I think he was tired of fighting.
Your avatar
Iâ€™m sorry to hear that it should be very difficult to lose the father
Empathize
10/05/20 3:15 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
How did you cope with a losing father ? (No matching questions found.)
Question
10/05/20 3:15 PM MDT

Your avatar
How did you cope after you lost your father ?
Question
10/05/20 3:16 PM MDT

Brian Foster
Yeah. He died of colon cancer. He also had high blood pressure and high cholesterol.
Your avatar
Sorry to hear that
Empathize
10/05/20 3:16 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Whoâ€™s your motherâ€™s health ?
Question
10/05/20 3:16 PM MDT

Brian Foster
She has type 2 diabetes and some high blood pressure, but I think sheâ€™s doing pretty well for 80.
Your avatar
Do you have a brothers and sisters ?
Question
10/05/20 3:17 PM MDT

Brian Foster
I have a sister, and I had a brother but he died many years ago.
Your avatar
Sorry to hear that
Empathize
10/05/20 3:17 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
How was your maternal grandmother ? (Clarified to How is the health of your maternal grandmother?.)
Question
10/05/20 3:17 PM MDT

Brian Foster
She had breast cancer. She was in her 60s when she died. (Clarified to how my maternal grandmotherâ€™s health is.)
Your avatar
About maternal grandfather ?
Question
10/05/20 3:18 PM MDT

Brian Foster
My grandfather on my momâ€™s side died of a heart attack. He was in his mid-fifties.
Your avatar
Sorry to hear that
Empathize
10/05/20 3:18 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
How is your paternal grandfather ?
Question
10/05/20 3:18 PM MDT

Brian Foster
He was healthy right up until he died. He went in his sleep at 85, and we just called it old age.
Your avatar
Sorry to hear that
Empathize
10/05/20 3:19 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
How about fraternal grandmother ? (No matching questions found.)
Question
10/05/20 3:19 PM MDT

Your avatar
How about paternal grandmother ?
Question
10/05/20 3:19 PM MDT

Brian Foster
She died of pneumonia when she was almost 80. 78 or 79, I think.
Your avatar
Sorry to hear that
Empathize
10/05/20 3:20 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Do you have children ?
Question
10/05/20 3:20 PM MDT

Brian Foster
Yes, I have two great kids. Well, theyâ€™re not kids. Sam is 26 and Allie is 19.
Your avatar
Does it have any medical conditions ?
Question
10/05/20 3:20 PM MDT

Brian Foster
The doctors told me I have a little bit of high blood pressure and cholesterol, but thatâ€™s it.
Your avatar
Is your daughter healthy ?
Question
10/05/20 3:21 PM MDT

Brian Foster
Allieâ€™s doing great. She has asthma, but sheâ€™s got a handle on it. [AUDIO COMING SOON]
Your avatar
How is your son doing ?
Question
10/05/20 3:21 PM MDT

Brian Foster
Heâ€™s 26.
Your avatar
Do you smoke ?
Question
10/05/20 3:21 PM MDT

Brian Foster
Nope, I had a lot of friends who did but I never started.
Your avatar
Do you drink ?
Question
10/05/20 3:21 PM MDT

Brian Foster
Sure, but never more than two or three beers on a weekend.
Your avatar
Do you do drugs ?
Question
10/05/20 3:22 PM MDT

Brian Foster
Nope.
Your avatar
Do you have any hobby ?
Question
10/05/20 3:22 PM MDT

Brian Foster
I like to fish, I like sports . . . letâ€™s see, I do some small electronics repair sometimes, and I go to my sonâ€™s bodybuilding competitions when I can.
Your avatar
Did you have any surgeries ?
Question
10/05/20 3:23 PM MDT

Brian Foster
Iâ€™ve never had any surgeries.
Your avatar
It is very good that you dont have any surgeries
Empathize
10/05/20 3:23 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Do you have any allergy ?
Question
10/05/20 3:24 PM MDT

Brian Foster
No, well . . . Iâ€™ve had a bad reaction to codeine before, but that is all I know of.NURS6512 Week 7 â€“ Focused Exam: Chest Pain Brian Foster Results
Your avatar
What type of reaction do you have to codeine ?
Question
10/05/20 3:24 PM MDT

Brian Foster
It makes me nauseous and I vomit.
Your avatar
How was your immunizations ? (Clarified to What immunizations have you had?.)
Question
10/05/20 3:25 PM MDT

Brian Foster
I donâ€™t remember exactly . . . maybe itâ€™s on my chart. (Clarified to what vaccines I have had.)
Your avatar
She hasnâ€™t been told that your cholesterol is always high ?
Question
10/06/20 6:29 AM MDT

Brian Foster
Iâ€™ve been told itâ€™s moderately high. Iâ€™ve never noticed any actual symptoms from that though.
Your avatar
Have you been tested for diabetes ?
Question
10/06/20 6:29 AM MDT

Brian Foster
My mom and my sister both have diabetes, but I donâ€™t have it.
Your avatar
Have you been monitoring your blood pressure ?
Question
10/06/20 6:29 AM MDT

Brian Foster
Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it.
Your avatar
Do you remember your last blood pressure reading ? (Clarified to Do you know your blood pressure number?.)
Question
10/06/20 6:30 AM MDT

Brian Foster
No, not offhand. (Clarified to if I know my blood pressure number.)
Your avatar
You need to monitor your blood pressure and you need to know your Baseline.
Educate
10/06/20 6:30 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Have you done any EKG recently ? (No matching questions found.)
Question
10/06/20 6:31 AM MDT

Your avatar
Did your doctor do any EKG ? (No matching questions found.)
Question
10/06/20 6:31 AM MDT

Your avatar
Any electrocardiogram ? (No matching questions found.)
Question
10/06/20 6:32 AM MDT

Your avatar
EKG done ? (Clarified to When was your last EKG?.)
Question
10/06/20 6:32 AM MDT

Brian Foster
I had one about three months ago. They usually put one on me at my annual physical. (Clarified to when my last EKG was.)
Your avatar
Well, EKG shows your heart monitoring, it will give us an idea how is your heart works.
Educate
10/06/20 6:34 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
What was the result of EKG ?
Question
10/06/20 6:34 AM MDT

Brian Foster
I donâ€™t remember the actual results, but as far as I know, it was normal.
Your avatar
Do you have a primary care provider ? Clinical Focused SOAP Note For Chest Pain Discussion
Question
10/06/20 6:34 AM MDT

Brian Foster
Dr. Melinda Smith.
Your avatar
It is Good that you have one.
Educate
10/06/20 6:35 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
When your last visit your primary care provider ?
Question
10/06/20 6:35 AM MDT

Brian Foster
I had a physical about 3 months ago.
Your avatar
Do you have stress ?
Question
10/06/20 6:36 AM MDT

Brian Foster
Not usually, but Iâ€™m feeling pretty anxious not knowing whatâ€™s going on with my chest.
Your avatar
Iâ€™m sorry to hear that
Empathize
10/06/20 6:36 AM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Do your exercise ?
Question
10/06/20 6:37 AM MDT

Brian Foster
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I havenâ€™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 Iâ€™ve been having.
Your avatar
Iâ€™m sorry that chest pain makes you not exercise
Empathize
10/06/20 6:37 AM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Do you drink water regularly ?
Question
10/06/20 6:37 AM MDT

Brian Foster
I usually drink water all day at work. At least four glasses, probably more. [AUDIO COMING SOON]
Your avatar
Letâ€™s go to take water
Educate
10/06/20 6:38 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Do you drink alcohol ?
Question
10/06/20 6:39 AM MDT

Brian Foster
Sure, but never more than two or three beers on a weekend.
Your avatar
Thatâ€™s moderate drinking
Educate
10/06/20 6:39 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Do you have a fever ?
Question
10/06/20 6:40 AM MDT

Brian Foster
I havenâ€™t had a fever, no.
Your avatar
They have a chills ?
Question
10/06/20 6:40 AM MDT

Brian Foster
I havenâ€™t had chills, no.
Your avatar
Do you have fatigue ?
Question
10/06/20 6:40 AM MDT

Brian Foster
Iâ€™m not more tired than normal.
Your avatar
Do you have night sweats ?
Question
10/06/20 6:41 AM MDT

Brian Foster
Nope, no night sweats.
Your avatar
Do you have thought the dacianpalpitations ?
Question
10/06/20 6:41 AM MDT

Brian Foster
Nah, I donâ€™t think about stuff like that. Iâ€™m happy with my life.
Your avatar
Do you have palpitations ?
Question
10/06/20 6:41 AM MDT

Brian Foster
I donâ€™t think so. I havenâ€™t noticed any.
Your avatar
Do you have angina ?
Question
10/06/20 6:42 AM MDT

Brian Foster
Iâ€™ve never been diagnosed with angina. [AUDIO COMING SOON]
Your avatar
Have you ever had edema ?
Question
10/06/20 6:42 AM MDT

Brian Foster
I havenâ€™t noticed any swelling.
Your avatar
Have you had any blood clots ?
Question
10/06/20 6:42 AM MDT

Brian Foster
Not that I know of.
Your avatar
Any history of rheumatic fever ?
Question
10/06/20 6:43 AM MDT

Brian Foster
No, I never had that.
Your avatar
Any history of heart murmur ?
Question
10/06/20 6:43 AM MDT

Brian Foster
No, none that I know of.
Your avatar
? (No matching questions found.)
Question
10/06/20 6:43 AM MDT

Your avatar
Do you have a cough ?
Question
10/06/20 6:43 AM MDT

Brian Foster
I donâ€™t have a cough.
Your avatar
Do you have difficulty breathing ?
Question
10/06/20 6:44 AM MDT

Brian Foster
My breathingâ€™s fine.
Your avatar
Do you have sore throat ?
Question
10/06/20 6:44 AM MDT

Brian Foster
I havenâ€™t had a sore throat in a long time.
Your avatar
Do you have change in sense of taste ?
Question
10/06/20 6:45 AM MDT

Brian Foster
I can still taste things fine.
Your avatar
Do you have any dysphasia ? (No matching questions found.)
Question
10/06/20 6:45 AM MDT

Your avatar
Do you have problem with swallowing ?
Question
10/06/20 6:45 AM MDT

Brian Foster
I havenâ€™t had any trouble swallowing.
Your avatar
Do you have nausea ?
Question
10/06/20 6:45 AM MDT

Brian Foster
No, I havenâ€™t felt nauseous. I just had pain in my chest.
Your avatar
Do you have diarrhea ?
Question
10/06/20 6:46 AM MDT

Brian Foster
I have, but it is very rare for me.
Your avatar
Do you have constipation ?
Question
10/06/20 6:46 AM MDT

Brian Foster
I havenâ€™t had problems with that. I wish it were only that.
Your avatar
Do you have any family history of heart attack ?
Question
10/06/20 6:46 AM MDT

Brian Foster
Well, my momâ€™s dad died of a heart attack. He was pretty young too.
Your avatar
Do you have a family history of a stroke ?
Question
10/06/20 6:47 AM MDT

Brian Foster
No, none that I know of.
Your avatar
Measured vitals
Exam Action
10/06/20 6:49 AM MDT

Your avatar
Mr. Foster, Thank you for answering my questions now Iâ€™m going to do physical examination
Educate
10/06/20 6:49 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Tested blood pressure in left arm with cuff
Exam Action
10/06/20 6:51 AM MDT

Your avatar
Tested blood pressure in right arm with cuff
Exam Action
10/06/20 6:51 AM MDT

Your avatar
Measured vitals
Exam Action
10/06/20 6:51 AM MDT

Your avatar
Inspected face
Exam Action
10/06/20 6:51 AM MDT

Your avatar
Inspected for jugular venous distension: No jugular venous distention; JVP 3 cm above sternal angle
Exam Action
10/06/20 6:52 AM MDT

Your avatar
Inspected anterior chest wall
Exam Action
10/06/20 6:52 AM MDT

Your avatar
Inspected left side of abdomen
Exam Action
10/06/20 6:53 AM MDT

Your avatar
Inspected front of abdomen
Exam Action
10/06/20 6:53 AM MDT

Your avatar
Inspected left side of abdomen
Exam Action
10/06/20 6:53 AM MDT

Your avatar
Inspected right hand: no visible abnormal findings
Exam Action
10/06/20 6:54 AM MDT

Your avatar
Inspected left hand: no visible abnormal findings
Exam Action
10/06/20 6:54 AM MDT

Your avatar
Inspected fingernails of right hand
Exam Action
10/06/20 6:55 AM MDT

Your avatar
Inspected fingernails of left hand
Exam Action
10/06/20 6:55 AM MDT

Your avatar
Inspected left leg
Exam Action
10/06/20 6:56 AM MDT

Your avatar
Inspected right leg
Exam Action
10/06/20 6:56 AM MDT

Your avatar
Inspected toenails on left foot
Exam Action
10/06/20 6:56 AM MDT

Your avatar
Inspected toenails on right foot
Exam Action
10/06/20 6:57 AM MDT

Your avatar
Inspected left leg
Exam Action
10/06/20 6:57 AM MDT

Your avatar
Inspected right leg
Exam Action
10/06/20 6:57 AM MDT

Your avatar
Inspected right leg for edema: No edema
Exam Action
10/06/20 6:58 AM MDT

Your avatar
Inspected left leg for edema: No edema
Exam Action
10/06/20 6:58 AM MDT

Your avatar
Checked capillary refill in fingernails
Exam Action
10/06/20 6:58 AM MDT

Your avatar
Checked capillary refill in fingernails
Exam Action
10/06/20 6:59 AM MDT

Your avatar
Auscultated right carotid pulse: Bruit present
Exam Action
10/06/20 6:59 AM MDT

Your avatar
Auscultated left carotid pulse
Exam Action
10/06/20 6:59 AM MDT

Your avatar
Auscultated right carotid pulse: Bruit present
Exam Action
10/06/20 6:59 AM MDT

Your avatar
Auscultated left carotid pulse
Exam Action
10/06/20 7:00 AM MDT

Your avatar
Auscultated right carotid pulse: Bruit present
Exam Action
10/06/20 7:00 AM MDT

Your avatar
Auscultated aortic area with the bell
Exam Action
10/06/20 7:01 AM MDT

Your avatar
Auscultated pulmonic area with the bell
Exam Action
10/06/20 7:01 AM MDT

Your avatar
Auscultated Erbâ€™s point with the bell
Exam Action
10/06/20 7:01 AM MDT

Your avatar
Auscultated tricuspid area with the bell
Exam Action
10/06/20 7:01 AM MDT

Your avatar
Auscultated mitral area with the bell
Exam Action
10/06/20 7:01 AM MDT

Your avatar
Auscultated breath sounds in anterior right upper lobe
Exam Action
10/06/20 7:02 AM MDT

Your avatar
Auscultated breath sounds in anterior left upper lobe
Exam Action
10/06/20 7:02 AM MDT

Your avatar
Auscultated breath sounds in anterior right middle lobe
Exam Action
10/06/20 7:02 AM MDT

Your avatar
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Exam Action
10/06/20 7:02 AM MDT

Your avatar
Auscultated breath sounds in anterior right lower lobe
Exam Action
10/06/20 7:02 AM MDT

Your avatar
Auscultated breath sounds in anterior left lower lobe
Exam Action
10/06/20 7:02 AM MDT

Your avatar
Auscultated aorta in abdomen
Exam Action
10/06/20 7:03 AM MDT

Your avatar
Auscultated right renal pulse
Exam Action
10/06/20 7:03 AM MDT

Your avatar
Auscultated left renal pulse
Exam Action
10/06/20 7:04 AM MDT

Your avatar
Auscultated right iliac pulse
Exam Action
10/06/20 7:04 AM MDT

Your avatar
Auscultated left iliac pulse
Exam Action
10/06/20 7:04 AM MDT

Your avatar
Auscultated left femoral pulse
Exam Action
10/06/20 7:04 AM MDT

Your avatar
Auscultated right femoral pulse
Exam Action
10/06/20 7:04 AM MDT

Your avatar
Auscultated right upper quadrant
Exam Action
10/06/20 7:04 AM MDT

Your avatar
Auscultated left upper quadrant
Exam Action
10/06/20 7:04 AM MDT

Your avatar
Auscultated left lower quadrant
Exam Action
10/06/20 7:04 AM MDT

Your avatar
Auscultated right lower quadrant
Exam Action
10/06/20 7:04 AM MDT

Your avatar
Auscultated over liver
Exam Action
10/06/20 7:05 AM MDT

Your avatar
Auscultated over spleen
Exam Action
10/06/20 7:05 AM MDT

Your avatar
Palpated right carotid pulse: Thrill, 3+
Exam Action
10/06/20 7:05 AM MDT

Your avatar
Palpated left carotid pulse: No thrill, 2+
Exam Action
10/06/20 7:06 AM MDT

Your avatar
Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm
Exam Action
10/06/20 7:06 AM MDT

Your avatar
Palpated right brachial pulse: No thrill, 2+
Exam Action
10/06/20 7:07 AM MDT

Your avatar
Palpated left brachial pulse: No thrill, 2+
Exam Action
10/06/20 7:07 AM MDT

Your avatar
Palpated right radial pulse: No thrill, 2+
Exam Action
10/06/20 7:18 AM MDT

Your avatar
Palpated left radial pulse: No thrill, 2+
Exam Action
10/06/20 7:19 AM MDT

Your avatar
Palpated right femoral pulse: No thrill, 2+
Exam Action
10/06/20 7:19 AM MDT

Your avatar
Palpated left femoral pulse: No thrill, 2+
Exam Action
10/06/20 7:19 AM MDT

Your avatar
Palpated right popliteal pulse: No thrill, 1+
Exam Action
10/06/20 7:20 AM MDT

Your avatar
Palpated left popliteal pulse: No thrill, 1+
Exam Action
10/06/20 7:20 AM MDT

Your avatar
Palpated right tibial pulse: No thrill, 1+
Exam Action
10/06/20 7:22 AM MDT

Your avatar
Palpated right tibial pulse: No thrill, 1+
Exam Action
10/06/20 7:23 AM MDT

Your avatar
Palpated left tibial pulse: No thrill, 1+
Exam Action
10/06/20 7:23 AM MDT

Your avatar
Palpated right dorsalis pedis pulse: No thrill, 1+
Exam Action
10/06/20 7:23 AM MDT

Your avatar
Palpated left dorsalis pedis pulse: No thrill, 1+
Exam Action
10/06/20 7:23 AM MDT

Your avatar
Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
Exam Action
10/06/20 7:25 AM MDT

Your avatar
Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
Exam Action
10/06/20 7:26 AM MDT

Your avatar
Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
Exam Action
10/06/20 7:26 AM MDT

Your avatar
Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension.NURS6512 Week 7 â€“ Focused Exam: Chest Pain Brian Foster Results
Exam Action
10/06/20 7:26 AM MDT

Your avatar
Percussed right upper quadrant
Exam Action
10/06/20 7:27 AM MDT

Your avatar
Percussed left upper quadrant
Exam Action
10/06/20 7:27 AM MDT

Your avatar
Percussed right lower quadrant
Exam Action
10/06/20 7:27 AM MDT

Your avatar
Percussed left lower quadrant
Exam Action
10/06/20 7:27 AM MDT

Your avatar
Percussed spleen
Exam Action
10/06/20 7:27 AM MDT

Your avatar
Percussed for liver span: 7 cm in the mid-clavicular line
Exam Action
10/06/20 7:28 AM MDT

Your avatar
Performed EKG
Exam Action
10/06/20 7:28 AM MDT

Your avatar
Thank you Mr. Foster. Iâ€™m done with physical evaluation
Educate
10/06/20 7:30 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Houston Foster how old are you ? (No matching questions found.)
Question
10/07/20 4:13 AM MDT

Your avatar
Mr.Foster how old are you ?
Question
10/07/20 4:13 AM MDT

Brian Foster
Iâ€™m 58 going on 30.
Your avatar
Early happy birthday
Empathize
10/07/20 4:14 AM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Is it physical activity activates the pain ?
Question
10/07/20 4:53 AM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
What aggravates your pain ?
Question
10/07/20 4:54 AM MDT

Brian Foster
Well, I think itâ€™s when Iâ€™m doing something physical most of the time. The first time it happened, my chest started hurting after I was doing some yard work. The second time happened when the elevator broke at work so I had to take the stairs. My office is on the 5th floor.
Your avatar
Do you like red meat ?
Question
10/07/20 5:59 AM MDT

Brian Foster
Yes, yes I do.
Your avatar
Do you like vegetables and fruits ?
Educate
10/07/20 5:59 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Do you like fruits and vegetables ? (No matching questions found.)
Question
10/07/20 5:59 AM MDT

Your avatar
If your diet include fruits and vegetables ? (No matching questions found.)
Question
10/07/20 6:00 AM MDT

Your avatar
You need to cut to read me like a beef pork and lamb because this meat is saturated with a bad cholesterol or fat. More than chicken and fish. Saturated and transfat can raise your blood cholesterol and make your heart disease worse.NURS6512 Week 7 â€“ Focused Exam: Chest Pain Brian Foster Results
Educate
10/07/20 6:05 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You can replace the red meat by chicken or fish like a salmon which has a good cholesterol which which will help you to reduce your bad cholesterol and help you with your heart and cholesterol problems.
Educate
10/07/20 6:07 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You need to start light exercising.
Educate
10/07/20 6:07 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You need to include fresh vegetables and fruit in your diet.
Educate
10/07/20 6:08 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You also need to continue taking your medications as prescribed.
Educate
10/07/20 6:08 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You also need to wait yourself daily in the same clothes in the same time.
Educate
10/07/20 6:09 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You need to do light exercise has three to four times a week.
Educate
10/07/20 6:09 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Mister Foster you need to follow up with a primary care physician and a cardiologist. (No matching questions found.)
Question
10/07/20 6:10 AM MDT

Your avatar
Mister Foster you need to follow up with a primary care physician and a cardiologist.
Educate
10/07/20 6:10 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You also need to eliminate you alcoholic beverages.
Educate
10/07/20 6:11 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
What is your height and weight ?
Question
10/07/20 6:13 AM MDT

Brian Foster
Iâ€™m five foot eleven.
Your avatar
What is your weight ?
Question
10/07/20 6:14 AM MDT

Brian Foster
As of this morning, a buck ninety-seven.
Your avatar
I am done with your exam Mr.Foster. Thank you for letting me to examine you. Have a good day. (No matching questions found.)
Question
10/09/20 7:43 AM MDT

Your avatar
I am done with your exam Mr.Foster. Thank you for letting me to examine you. Have a good day.
Educate
10/09/20 7:43 AM MDT

Brian Foster
EducateSpeech
Your avatar
Mr. Foster I just wanted to partially examine you again (No matching questions found.)
Question
10/12/20 1:39 AM MDT

Your avatar
Mr. Foster I just wanted to partially examine you again
Educate
10/12/20 1:40 AM MDT

Brian Foster
EducateSpeech
Your avatar
Auscultated over liver
Exam Action
10/12/20 1:40 AM MDT

Your avatar
Auscultated over spleen
Exam Action
10/12/20 1:41 AM MDT

Your avatar
Auscultated over liver
Exam Action
10/12/20 1:41 AM MDT

Your avatar
Percussed right upper quadrant
Exam Action
10/12/20 1:43 AM MDT

Your avatar
Percussed left upper quadrant
Exam Action
10/12/20 1:43 AM MDT

Your avatar
Percussed right lower quadrant
Exam Action
10/12/20 1:43 AM MDT

Your avatar
Percussed left lower quadrant
Exam Action
10/12/20 1:43 AM MDT

Your avatar
Thank you Mr. Foster. I am done.
Educate
10/12/20 1:50 AM MDT

Brian Foster
EducateSpeech
Your avatar
Percussed spleen
Exam Action
10/18/20 5:58 PM MDT

Your avatar
Percussed spleen
Exam Action
10/18/20 5:58 PM MDT

Your avatar
Inspected left leg
Exam Action
10/18/20 6:24 PM MDT

Your avatar
Inspected right leg
Exam Action
10/18/20 6:24 PM MDT

Your avatar
Inspected toenails on left foot
Exam Action
10/18/20 6:24 PM MDT

Your avatar
Inspected left leg
Exam Action
10/18/20 6:24 PM MDT

Your avatar
Inspected right leg
Exam Action
10/18/20 6:24 PM MDT

Your avatar
Inspected toenails on right foot
Exam Action
10/18/20 6:25 PM MDT

Your avatar
Inspected left leg
Exam Action
10/18/20 6:25 PM MDT

Your avatar
Inspected right leg
Exam Action
10/18/20 6:25 PM MDT

Your avatar
Inspected toenails on left foot
Exam Action
10/18/20 6:25 PM MDT

Your avatar
Inspected right leg for edema: No edema
Exam Action
10/18/20 6:25 PM MDT

Your avatar
Inspected left leg for edema: No edema
Exam Action
10/18/20 6:25 PM MDT

Your avatar
Auscultated aortic area with the bell
Exam Action
10/18/20 6:26 PM MDT

Your avatar
Auscultated pulmonic area with the bell
Exam Action
10/18/20 6:26 PM MDT

Your avatar
Auscultated Erbâ€™s point with the bell
Exam Action
10/18/20 6:26 PM MDT

Your avatar
Auscultated tricuspid area with the bell
Exam Action
10/18/20 6:26 PM MDT

Your avatar
Auscultated mitral area with the bell
Exam Action
10/18/20 6:26 PM MDT

Your avatar
Auscultated aortic area with the bell
Exam Action
10/18/20 6:27 PM MDT

Your avatar
Auscultated pulmonic area with the bell
Exam Action
10/18/20 6:27 PM MDT

Your avatar
Auscultated Erbâ€™s point with the bell
Exam Action
10/18/20 6:27 PM MDT

Your avatar
Auscultated tricuspid area with the bell
Exam Action
10/18/20 6:27 PM MDT

Your avatar
Auscultated mitral area with the bell
Exam Action
10/18/20 6:27 PM MDT

Your avatar
Percussed right upper quadrant
Exam Action
10/18/20 6:28 PM MDT

Your avatar
Percussed left upper quadrant
Exam Action
10/18/20 6:28 PM MDT

Your avatar
Percussed right lower quadrant
Exam Action
10/18/20 6:28 PM MDT

Your avatar
Percussed left lower quadrant
Exam Action
10/18/20 6:28 PM MDT

Your avatar
Inspected left leg
Exam Action
10/18/20 6:31 PM MDT

Your avatar
Inspected right leg
Exam Action
10/18/20 6:31 PM MDT

Your avatar
Inspected toenails on left foot
Exam Action
10/18/20 6:31 PM MDT

Your avatar
Inspected toenails on right foot
Exam Action
10/18/20 6:31 PM MDT

Your avatar
Inspected toenails on left foot
Exam Action
10/18/20 6:32 PM MDT

Your avatar
Inspected toenails on right foot
Exam Action
10/18/20 6:32 PM MDT

Your avatar
Inspected left leg
Exam Action
10/18/20 6:32 PM MDT

Your avatar
Inspected right leg
Exam Action
10/18/20 6:32 PM MDT

Your avatar
Inspected right leg for edema: No edema
Exam Action
10/18/20 6:32 PM MDT

Your avatar
Inspected left leg for edema: No edema
Exam Action
10/18/20 6:32 PM MDT

Your avatar
Measured vitals
Exam Action
10/18/20 6:39 PM MDT

Your avatar
Palpated right carotid pulse: Thrill, 3+
Exam Action
10/18/20 6:39 PM MDT

Your avatar
Palpated left carotid pulse: No thrill, 2+
Exam Action
10/18/20 6:39 PM MDT

Your avatar
Palpated right carotid pulse: Thrill, 3+
Exam Action
10/18/20 6:40 PM MDT

Your avatar
Palpated right carotid pulse: Thrill, 3+
Exam Action
10/18/20 6:41 PM MDT

Your avatar
Palpated left carotid pulse: No thrill, 2+
Exam Action
10/18/20 6:41 PM MDT

Your avatar
Auscultated aortic area with the bell
Exam Action
10/18/20 6:42 PM MDT

Your avatar
Auscultated pulmonic area with the bell
Exam Action
10/18/20 6:42 PM MDT

Your avatar
Auscultated Erbâ€™s point with the bell
Exam Action
10/18/20 6:42 PM MDT

Your avatar
Auscultated tricuspid area with the bell
Exam Action
10/18/20 6:42 PM MDT

Your avatar
Auscultated mitral area with the bell
Exam Action
10/18/20 6:42 PM MDT

Your avatar
Auscultated mitral area with the diaphragm
Exam Action
10/18/20 6:42 PM MDT

Your avatar
Auscultated mitral area with the bell
Exam Action
10/18/20 6:42 PM MDT

Your avatar
Auscultated tricuspid area with the bell
Exam Action
10/18/20 6:42 PM MDT

Your avatar
Auscultated Erbâ€™s point with the bell
Exam Action
10/18/20 6:42 PM MDT

Your avatar
Auscultated pulmonic area with the bell
Exam Action
10/18/20 6:42 PM MDT

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Auscultated aortic area with the bell
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10/18/20 6:42 PM MDT

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Auscultated pulmonic area with the bell
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10/18/20 6:42 PM MDT

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Auscultated Erbâ€™s point with the bell
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10/18/20 6:42 PM MDT

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Auscultated tricuspid area with the bell
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10/18/20 6:43 PM MDT

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Auscultated tricuspid area with the diaphragm
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10/18/20 6:43 PM MDT

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Auscultated mitral area with the diaphragm
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10/18/20 6:43 PM MDT

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Auscultated mitral area with the bell
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10/18/20 6:43 PM MDT

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Auscultated tricuspid area with the bell
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10/18/20 6:43 PM MDT

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Auscultated Erbâ€™s point with the bell
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10/18/20 6:43 PM MDT

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Auscultated pulmonic area with the bell
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10/18/20 6:43 PM MDT

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Auscultated aortic area with the bell
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10/18/20 6:43 PM MDT

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Measured vitals
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10/18/20 6:44 PM MDT

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Inspected right hand: no visible abnormal findings
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10/18/20 6:44 PM MDT

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Inspected left hand: no visible abnormal findings
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10/18/20 6:44 PM MDT

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Inspected left leg
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10/18/20 6:44 PM MDT

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Inspected right leg
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10/18/20 6:44 PM MDT

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Inspected toenails on left foot
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10/18/20 6:44 PM MDT

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Inspected toenails on right foot
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10/18/20 6:44 PM MDT

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Inspected right hand: no visible abnormal findings
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10/18/20 6:45 PM MDT

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Inspected left hand: no visible abnormal findings
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10/18/20 6:45 PM MDT

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Inspected fingernails of left hand
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10/18/20 6:45 PM MDT

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Inspected fingernails of right hand
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10/18/20 6:45 PM MDT

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Inspected fingernails of left hand
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10/18/20 6:46 PM MDT

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Inspected fingernails of right hand
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10/18/20 6:46 PM MDT

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Inspected right hand: no visible abnormal findings
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10/18/20 7:19 PM MDT

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Inspected left hand: no visible abnormal findings
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10/18/20 7:19 PM MDT

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Inspected left leg
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10/18/20 7:20 PM MDT

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Inspected right leg
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10/18/20 7:20 PM MDT

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Are you working ?
Question
10/18/20 9:42 PM MDT

Brian Foster
I work at a civil engineering firm here in town.
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Do your sit a lot at work ? (Clarified to Do you sit down for long periods of time at work?.)
Question
10/18/20 9:43 PM MDT

Brian Foster
Well, yes, thatâ€™s the job. Unless Iâ€™m on site. [AUDIO COMING SOON] (Clarified to if I spend a lot of time sitting at work.)NURS6512 Week 7 â€“ Focused Exam: Chest Pain Brian Foster Results
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What is the hours of working ?
Question
10/18/20 9:46 PM MDT

Brian Foster
Iâ€™m an engineer.
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What is the working hours ?
Question
10/18/20 9:46 PM MDT

Brian Foster
My work life is pretty stable and generally low stress, Iâ€™d say.
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Itâ€™s really good
Empathize
10/18/20 9:46 PM MDT

Brian Foster
EmpathizeSpeech
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Do you like your job ?
Question
10/18/20 9:47 PM MDT

Brian Foster
Yeah, I like it. Iâ€™ve been there sixteen years.
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Itâ€™s awesome
Empathize
10/18/20 9:47 PM MDT

Brian Foster
EmpathizeSpeech
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Do you have a friends ?
Question
10/18/20 9:47 PM MDT

Brian Foster
Yep.
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What type of social support do you have ? (No matching questions found.)
Question
10/18/20 9:48 PM MDT

ORDER TODAY

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Where your socialize ?
Question
10/18/20 9:48 PM MDT

Brian Foster
My social life is mostly my family now. My wife and I are together all the time, and my son and his family lives in town. My daughter is in college so sheâ€™s home at least once a month. We try to have big family dinners when sheâ€™s home. I go fishing with my friend Smitty and his brother every once in a while.
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How often do you go to fishing ? (Clarified to How often do you go to church?.)
Question
10/18/20 9:51 PM MDT

Brian Foster
I donâ€™t usually go unless itâ€™s on a holiday when my mother is in town. (Clarified to how often I go to church.)
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How often do mother comes in town ?
Question
10/18/20 9:51 PM MDT

Brian Foster
I think I pee a normal amount. Every couple of hours or so.

Clinical Focused SOAP Note For Chest Pain Discussion