Focused Exam: Chest Pain, Brian Foster Shadow health transcript
Hello
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Greet |
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Good morning.
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What brings you in today?
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I have been having some troubling chest pain in my chest now and then for the past month.
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Sorry for the chest problem
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Empathize |
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Thanks. I appreciate that.
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When did the chest pain start?
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I first noticed it earlier this month. I thought it might just be heartburn and it passed after a couple of minutes.
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How is the pain like
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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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Where is the pain located?
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When the pain happens, I feel it mostly in the middle of my chest, over my heart.
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Does the chest pain radiate?
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The pain doesn’t radiate anywhere. It’s mostly just right in the middle of my chest.
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Do you have back pain?
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I haven’t had back pain, no.
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How frequent are the chest pains?
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Well, it has happened three times the past month. It usually goes away after about a couple of minutes.
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What relieves the chest pain?
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I’m not sure. I think lying still seems to help a little.
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What makes the pain worse
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Well, I think it’s when I’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.
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can you rate the pain on a scale
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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.
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Have you taken any medications for the chest pain
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No, not yet.
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Which medications do you take currently (Clarified to What medications do you take?.)
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Yeah, let’s see, I take atorvastatin for cholesterol, lisinopril for blood pressure. . . Oh yeah, and I take fish oil too. I hear that’s good for your cholesterol. (Clarified to what medications I am taking.)
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Thats good for your cholesterol, continue taking it
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Educate |
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Good to know. Thank you. Focused Exam: Chest Pain, Brian Foster Shadow health transcript
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Any allergies
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No, well . . . I’ve had a bad reaction to codeine before, but that is all I know of.
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Any history of chronic illness?
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Besides a little high blood pressure and cholesterol, no.
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Have you done EKG test recently?
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I had one about three months ago. They usually put one on me at my annual physical.
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What were the results of the EKG?
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I don’t remember the actual results, but as far as I know, it was normal.
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Do you have a primary care provider?
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Dr. Melinda Smith.
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Great
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Educate |
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Good to know. Thank you.
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When did you last visit your care provider
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I had a physical about 3 months ago.
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Any palpitations?
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I don’t think so. I haven’t noticed any.
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Any history of heart illness? (Clarified to Do you have a history of heart problems?.)
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All I know is I have high blood pressure and cholesterol, but that’s pretty well-controlled by medicine as far as I know. (Clarified to if I have a history of heart problems.)
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Do you feel stressed?
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Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest.
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I’m sorry about that
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Empathize |
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Thanks. I appreciate that.
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Do you have hypertension?
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Yes, I supposedly have moderately high blood pressure.
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Do you exercise?
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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.
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I’m sorry you’ve not been able to exercise
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Empathize |
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Thanks. I appreciate that.
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What is your typical diet
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I try to stay conscious of my diet. You know, I watch the fat. I watch the sodium . . . but I’m a dyed-in-the-wool carnivore too. Steaks and burgers find their way in there every once in a while.
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Do you drink water regularly?
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I usually drink water all day at work. At least four glasses, probably more.
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Do you smoke cigarette?
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Nope, I had a lot of friends who did but I never started.
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Smoking is bad for the health
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Educate |
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Good to know. Thank you.
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Do you take alcohol? Focused Exam: Chest Pain, Brian Foster Shadow health transcript
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Sure, but never more than two or three beers on a weekend.
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Do you feel fatigued?
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I’m not more tired than normal.
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Any dizziness?
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No, I haven’t felt dizzy.
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Do you have Angina?
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I’ve never been diagnosed with angina.
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Do you have edema?
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I haven’t noticed any swelling.
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Have you has blood clots?
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Not that I know of.
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Any fever?
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I haven’t had a fever, no.
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Do you cough?
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I don’t have a cough.
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Any difficulty breathing?
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My breathing’s fine.
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Any sore throat?
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I haven’t had a sore throat in a long time.
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Do you have diarrhea?
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I have, but it is very rare for me.
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Do you have constipation?
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I haven’t had problems with that. I wish it were only that.
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Any heartburn?
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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.
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Any family history of hear attack?
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No, nobody had that.
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Have you been monitoring your blood pressure?
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Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it.
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Measured vitals
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Tested blood pressure in left arm with cuff
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Tested blood pressure in right arm with cuff
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Measured vitals
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Inspected face
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Inspected for jugular venous distension: No jugular venous distention; JVP 3 cm above sternal angle
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Inspected anterior chest wall
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Inspected right side chest wall
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Inspected posterior chest wall
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Inspected left side chest wall
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Inspected left side of abdomen
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Inspected front of abdomen
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Inspected right hand: no visible abnormal findings
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Inspected left hand: no visible abnormal findings
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Inspected fingernails of left hand Focused Exam: Chest Pain, Brian Foster Shadow health transcript
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Inspected right hand: no visible abnormal findings
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Inspected left hand: no visible abnormal findings
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Inspected fingernails of right hand
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Inspected left leg
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Inspected right leg Focused Exam: Chest Pain, Brian Foster Shadow health transcript
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Inspected toenails on left foot
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Inspected toenails on right foot
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Inspected left leg
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Inspected right leg
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Inspected right leg for edema: No edema
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Inspected left leg for edema: No edema
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Auscultated right carotid pulse: Bruit present
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Auscultated left carotid pulse
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Auscultated aortic area with the bell
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Auscultated aortic area with the diaphragm
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Auscultated pulmonic area with the diaphragm
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Auscultated pulmonic area with the bell
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Auscultated Erb’s point with the bell
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Auscultated Erb’s point with the diaphragm
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Auscultated tricuspid area with the diaphragm
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Auscultated tricuspid area with the bell
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Auscultated tricuspid area with the diaphragm
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Auscultated mitral area with the diaphragm
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Auscultated mitral area with the bell
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Auscultated breath sounds in anterior right upper lobe
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Auscultated breath sounds in anterior left upper lobe
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Auscultated breath sounds in anterior right middle lobe
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Auscultated breath sounds in anterior left mid-chest (upper lobe)
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Auscultated breath sounds in anterior right lower lobe
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Auscultated breath sounds in anterior left lower lobe
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Auscultated breath sounds in posterior left upper lobe
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Auscultated breath sounds in posterior right upper lobe
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Auscultated breath sounds in posterior left mid-back (lower lobe)
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Auscultated breath sounds in posterior right mid-back (lower lobe)
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Auscultated breath sounds in posterior left lower lobe
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Auscultated breath sounds in posterior right lower lobe
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Auscultated breath sounds in posterior left lower lobe on side
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Auscultated breath sounds in posterior right lower lobe on side
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Auscultated aorta in abdomen
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Auscultated right renal pulse
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Auscultated left renal pulse
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Auscultated right iliac pulse
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Auscultated left iliac pulse
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Auscultated right femoral pulse
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Auscultated left femoral pulse
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Auscultated right upper quadrant
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Auscultated left upper quadrant
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Auscultated right lower quadrant
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Auscultated left lower quadrant
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Auscultated over liver Focused Exam: Chest Pain, Brian Foster Shadow health transcript
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Auscultated over spleen
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Palpated right carotid pulse: Thrill, 3+
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Palpated right carotid pulse: Thrill, 3+
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Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm
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Palpated right brachial pulse: No thrill, 2+
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Palpated left brachial pulse: No thrill, 2+
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Palpated right radial pulse: No thrill, 2+
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Palpated left radial pulse: No thrill, 2+
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Palpated right femoral pulse: No thrill, 2+
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Palpated left femoral pulse: No thrill, 2+
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Palpated right popliteal pulse: No thrill, 1+
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Palpated left popliteal pulse: No thrill, 1+
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Palpated right tibial pulse: No thrill, 1+
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Palpated left tibial pulse: No thrill, 1+
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Palpated right dorsalis pedis pulse: No thrill, 1+
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Palpated left dorsalis pedis pulse: No thrill, 1+
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Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
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Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
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Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
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Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
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Palpated right upper quadrant with deep pressure: No masses
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Palpated left upper quadrant with deep pressure: No masses
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Palpated right lower quadrant: with deep pressure: No masses
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Palpated left lower quadrant with deep pressure: No masses
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Palpated liver: Palpable 1 cm below right costal margin
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Palpated for spleen: Not palpable
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Palpated for right kidney: Not palpable
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Palpated for left kidney: Not palpable
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Tested skin turgor
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Percussed right upper quadrant
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Percussed left upper quadrant
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Percussed right lower quadrant
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Percussed left lower quadrant
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Percussed spleen
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Percussed for liver span: 7 cm in the mid-clavicular line Focused Exam: Chest Pain, Brian Foster Shadow health transcript
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Fatima Khan Endocrine System Hourly Rounds Shadow health Objective data
Focused Exam: Chest Pain, Brian Foster Shadow health transcript
Transcript
Your Avatar.
Hello
Greet
04/15/23 1:09 PM EDT
Brian Foster.
Good morning.
Your Avatar.
What brings you in today?
Question
04/15/23 1:09 PM EDT
Brian Foster.
I have been having some troubling chest pain in my chest now and then for the past month.
Your Avatar.
Sorry for the chest problem
Empathize
04/15/23 1:10 PM EDT
Brian Foster.
Thanks. I appreciate that.
Your Avatar.
When did the chest pain start?
Question
04/15/23 1:11 PM EDT
Brian Foster.
I first noticed it earlier this month. I thought it might just be heartburn and it passed after a couple of minutes.
Your Avatar.
How is the pain like
Question
04/15/23 1:13 PM EDT
Brian Foster.
Well, it doesn’t hurt right now, but I have been having chest pain now and then for the past month.
Your Avatar.
Where is the pain located?
Question
04/15/23 1:13 PM EDT
Brian Foster.
When the pain happens, I feel it mostly in the middle of my chest, over my heart.
Your Avatar.
Does the chest pain radiate?
Question
04/15/23 1:14 PM EDT
Brian Foster.
The pain doesn’t radiate anywhere. It’s mostly just right in the middle of my chest.
Your Avatar.
Do you have back pain?
Question
04/15/23 1:15 PM EDT
Brian Foster.
I haven’t had back pain, no.
Your Avatar.
How frequent are the chest pains?
Question
04/15/23 1:16 PM EDT
Brian Foster.
Well, it has happened three times the past month. It usually goes away after about a couple of minutes.
Your Avatar.
What relieves the chest pain?
Question
04/15/23 1:17 PM EDT
Brian Foster.
I’m not sure. I think lying still seems to help a little.
Your Avatar.
What makes the pain worse
Question
04/15/23 1:17 PM EDT
Brian Foster.
Well, I think it’s when I’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.
Can you rate the pain on a scale
Question
04/15/23 1:18 PM EDT
Brian Foster.
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.
Your Avatar.
Have you taken any medications for the chest pain
Question
04/15/23 1:20 PM EDT
Brian Foster.
No, not yet.
Your Avatar.
Which medications do you take currently?
Question
04/15/23 1:21 PM EDT
Brian Foster.
Yeah, let’s see, I take atorvastatin for cholesterol, lisinopril for blood pressure. . . Oh yeah, and I take fish oil too. I hear that’s good for your cholesterol.
Your Avatar.
That’s good for your cholesterol, continue taking it
Educate
04/15/23 1:22 PM EDT
Brian Foster.
Good to know. Thank you.
Your Avatar.
Any allergies
Question
04/15/23 1:23 PM EDT
Brian Foster.
No, well . . . I’ve had a bad reaction to codeine before, but that is all I know of.
Your Avatar.
Any history of chronic illness?
Question
04/15/23 1:24 PM EDT
Brian Foster.
Besides a little high blood pressure and cholesterol, no.
Your Avatar.
Have you done EKG test recently?
Question
04/15/23 1:24 PM EDT
Brian Foster.
I had one about three months ago. They usually put one on me at my annual physical.
Your Avatar.
What were the results of the EKG?
Question
04/15/23 1:25 PM EDT
Brian Foster.
I don’t remember the actual results, but as far as I know, it was normal.
Your Avatar.
Do you have a primary care provider?
Question
04/15/23 1:25 PM EDT
Brian Foster.
Dr. Melinda Smith.
Your Avatar.
Great
Educate
04/15/23 1:26 PM EDT
Brian Foster.
Good to know. Thank you.
Your Avatar.
When did you last visit your care provider
Question
04/15/23 1:26 PM EDT
Brian Foster.
I had a physical about 3 months ago.
Your Avatar.
Any palpitations?
Question
04/15/23 1:27 PM EDT
Brian Foster.
I don’t think so. I haven’t noticed any.
Your Avatar.
Any history of heart illness?
Question
04/15/23 1:27 PM EDT
Brian Foster.
All I know is I have high blood pressure and cholesterol, but that’s pretty well-controlled by medicine as far as I know.
Your Avatar.
Do you feel stressed?
Question
04/15/23 1:28 PM EDT
Brian Foster.
Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest.
Your Avatar.
I’m sorry about that
Empathize
04/15/23 1:28 PM EDT
Brian Foster.
Thanks. I appreciate that.
Your Avatar.
Do you have hypertension?
Question
04/15/23 1:29 PM EDT
Brian Foster.
Yes, I supposedly have moderately high blood pressure.
Your Avatar.
Do you exercise?
Question
04/15/23 1:29 PM EDT
Brian Foster.
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.
Your Avatar.
I’m
sorry for the loss
Empathize
04/15/23 1:31 PM EDT
Brian Foster.
It’s okay. Thanks. I do miss my bike.
Your Avatar.
Any recent change in exercise?
Question
04/15/23 1:31 PM EDT
Brian Foster.
No, not really.
Your Avatar.
Do you smoke?
Question
04/15/23 1:31 PM EDT
Brian Foster.
I used to smoke but quit about 10 years ago. Best decision I ever made.
Your Avatar.
Congrats on quitting
Empathize
04/15/23 1:32 PM EDT
Brian Foster.
Thank you. It was tough, but worth it.
Your Avatar.
Do you drink alcohol?
Question
04/15/23 1:32 PM EDT
Brian Foster.
I have a beer or two on the weekends, but nothing excessive.
Your Avatar.
Any illegal drugs?
Question
04/15/23 1:33 PM EDT
Brian Foster.
No, I haven’t used any illegal drugs.
Your Avatar.
Is there a family history of heart disease
Question
04/15/23 1:33 PM EDT
Brian Foster.
Yeah, my dad had a heart attack when he was in his 50s.
Your Avatar.
Do you experience any dizziness
Question
04/15/23 1:34 PM EDT
Brian Foster.
No, I haven’t felt dizzy.
Your Avatar.
Do you have diabetes?
Question
04/15/23 1:34 PM EDT
Brian Foster.
No, I don’t have diabetes.
Your Avatar.
Do you have shortness of breath?
Question
04/15/23 1:35 PM EDT
Brian Foster.
Not usually, but it has happened a few times recently when I’ve had the chest pain.
Your Avatar.
Do you have a family history of lung disease?
Question
04/15/23 1:35 PM EDT
Brian Foster.
Not that I know of.
Your Avatar.
Do you have a history of high cholesterol?
Question
04/15/23 1:36 PM EDT
Brian Foster.
Yes, I have high cholesterol. I take atorvastatin for it.
Your Avatar.
Any recent injury to your chest?
Question
04/15/23 1:37 PM EDT
Brian Foster.
No, I haven’t injured my chest.
Your Avatar.
Do you have a history of acid reflux?
Question
04/15/23 1:37 PM EDT
Brian Foster.
No, I don’t have acid reflux.
Your Avatar.
Do you have a history of smoking
Question
04/15/23 1:38 PM EDT
Brian Foster.
I used to smoke but quit about 10 years ago. Best decision I ever made.
Your Avatar.
Congrats on quitting
Empathize
04/15/23 1:38 PM EDT
Brian Foster.
Thank you. It was tough, but worth it.
Your Avatar.
Do you have a history of alcoholism
Question
04/15/23 1:38 PM EDT
Brian Foster.
No, I don’t have a history of alcoholism.
Your Avatar.
Do you have a history of drug abuse
Question
04/15/23 1:39 PM EDT
Brian Foster.
No, I haven’t used any illegal drugs.
Your Avatar.
Do you have a history of anemia?
Question
04/15/23 1:39 PM EDT
Brian Foster.
No, I don’t have a history of anemia.
Your Avatar.
Do you have a history of chronic illness
Question
04/15/23 1:39 PM EDT
Brian Foster.
Besides high blood pressure and high cholesterol, no.
Your Avatar.
Do you have a history of heart disease?
Question
04/15/23 1:40 PM EDT
Brian Foster.
I don’t have a history of heart disease, but my dad had a heart attack in his 50s.
Your Avatar.
Do you have a history of lung disease?
Question
04/15/23 1:40 PM EDT
Brian Foster.
Not that I know of.
Your Avatar.
Any recent illnesses or infections?
Question
04/15/23 1:41 PM EDT
Brian Foster.
No, I haven’t been sick recently.
Your Avatar.
Any recent travel?
Question
04/15/23 1:41 PM EDT
Brian Foster.
No, I haven’t traveled recently.
Your Avatar.
Do you have a history of kidney disease?
Question
04/15/23 1:41 PM EDT
Brian Foster.
No, I don’t have kidney disease.
Your Avatar.
Do you have a history of liver disease?
Question
04/15/23 1:42 PM EDT
Brian Foster.
No, I don’t have liver disease.
Your Avatar.
Any history of cancer
Question
04/15/23 1:42 PM EDT
Brian Foster.
No, I don’t have a history of cancer.
Your Avatar.
Do you have any known allergies?
Question
04/15/23 1:42 PM EDT
Brian Foster.
I’ve had a bad reaction to codeine before, but that’s all I know of.
Your Avatar.
Any thyroid problems?
Question
04/15/23 1:43 PM EDT
Brian Foster.
No, I don’t have thyroid problems.
Your Avatar.
Any psychological disorders?
Question
04/15/23 1:43 PM EDT
Brian Foster.
No, I don’t have any psychological disorders.
Your Avatar.
Have you ever had surgery?
Question
04/15/23 1:43 PM EDT
Brian Foster.
I had my appendix removed when I was a kid, but nothing else.
Your Avatar.
Do you take any medications?
Question
04/15/23 1:44 PM EDT
Brian Foster.
Yes, I take atorvastatin for cholesterol, lisinopril for blood pressure, and fish oil as a supplement.
Your Avatar.
Alright, let’s have a look
Assessment
04/15/23 1:45 PM EDT
Brian Foster.
Thank you.
Your Avatar.
How is your appetite?
Question
04/15/23 1:45 PM EDT
Brian Foster.
My appetite is normal. I haven’t noticed any changes in that.
Your Avatar.
Any change in weight?
Question
04/15/23 1:45 PM EDT
Brian Foster.
No, my weight has been stable.
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Any vision changes?
Question
04/15/23 1:46 PM EDT
Brian Foster.
No, my vision has been fine.
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Any trouble swallowing?
Question
04/15/23 1:46 PM EDT
Brian Foster.
No, I haven’t had any trouble with swallowing.
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Do you have a history of sleep apnea?
Question
04/15/23 1:46 PM EDT
Brian Foster.
No, I don’t have a history of sleep apnea.
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Do you have a history of snoring?
Question
04/15/23 1:47 PM EDT
Brian Foster.
I snore occasionally, but it’s never been a chronic issue.
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Any history of gastrointestinal problems?
Question
04/15/23 1:47 PM EDT
Brian Foster.
No, I don’t have a history of gastrointestinal problems.
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Do you have a history of joint pain or arthritis?
Question
04/15/23 1:47 PM EDT
Brian Foster.
No, I don’t have joint pain or arthritis.
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Do you have a history of headaches?
Question
04/15/23 1:48 PM EDT
Brian Foster.
I get the occasional tension headache, but nothing severe or chronic.
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Any history of seizures?
Question
04/15/23 1:48 PM EDT
Brian Foster.
No, I haven’t had any seizures.
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Do you have a history of urinary problems?
Question
04/15/23 1:48 PM EDT
Brian Foster.
No, I don’t have urinary problems.
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Any history of skin problems?
Question
04/15/23 1:49 PM EDT
Brian Foster.
I’ve had some acne in the past, but that’s about it.
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Do you have a history of allergies?
Question
04/15/23 1:49 PM EDT
Brian Foster.
I had a bad reaction to codeine once, but I don’t have any other known allergies.
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Any history of immune system problems?
Question
04/15/23 1:49 PM EDT
Brian Foster.
Not that I’m aware of.
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Do you have a history of blood disorders?
Question
04/15/23 1:50 PM EDT
Brian Foster.
No, I don’t have a history of blood disorders.
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Any history of sexually transmitted infections?
Question
04/15/23 1:50 PM EDT
Brian Foster.
No, I haven’t had any sexually transmitted infections.
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Any history of bone disorders?
Question
04/15/23 1:50 PM EDT
Brian Foster.
No, I don’t have a history of bone disorders.
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Do you have a history of neurological problems?
Question
04/15/23 1:51 PM EDT
Brian Foster.
No, I don’t have a history of neurological problems.
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Any history of psychiatric illness?
Question
04/15/23 1:51 PM EDT
Brian Foster.
No, I don’t have a history of psychiatric illness.
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Do you have a history of substance abuse?
Question
04/15/23 1:51 PM EDT
Brian Foster.
No, I haven’t abused substances.
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Any history of developmental disorders?
Question
04/15/23 1:52 PM EDT
Brian Foster.
No, I don’t have a history of developmental disorders.
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Any history of psychiatric hospitalization?
Question
04/15/23 1:52 PM EDT
Brian Foster.
No, I haven’t been hospitalized for psychiatric reasons.
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Any history of self-harm?
Question
04/15/23 1:52 PM EDT
Brian Foster.
No, I haven’t engaged in self-harm.
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Any history of suicide attempts?
Question
04/15/23 1:53 PM EDT
Brian Foster.
No, I haven’t attempted suicide.
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Have you ever been diagnosed with a mental health condition?
Question
04/15/23 1:53 PM EDT
Brian Foster.
No, I haven’t been diagnosed with a mental health condition.
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Do you have a family history of mental illness?
Question
04/15/23 1:53 PM EDT
Brian Foster.
Not that I know of.
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Have you ever been diagnosed with a developmental disorder?
Question
04/15/23 1:54 PM EDT
Brian Foster.
No, I haven’t been diagnosed with a developmental disorder.
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Have you ever been hospitalized for a mental health condition?
Question
04/15/23 1:54 PM EDT
Brian Foster.
No, I haven’t been hospitalized for a mental health condition.
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Have you ever engaged in self-harm?
Question
04/15/23 1:54 PM EDT
Brian Foster.
No, I haven’t engaged in self-harm.
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Have you ever attempted suicide?
Question
04/15/23 1:54 PM EDT
Brian Foster.
No, I haven’t attempted suicide.
Your Avatar.
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