*NURSING > SHADOW HEALTH > NR 509 Brian Foster shadow health interview (GRADED A) (All)

NR 509 Brian Foster shadow health interview (GRADED A)

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Good morning. My name is I will be assessing you today. Hello what is your name Brian Robert Foster. what is your date of birth August 17 . . . [Mr. Foster reports the correct year.] [AUDIO CO... MING SOON] how old are you I'm 58 going on 30. how tall are you I'm five foot eleven. how much do you weigh As of this morning, a buck ninety-seven. Measured vitals Tested blood pressure in left arm with cuff Tested blood pressure in right arm with cuff Tested blood pressure in left arm with cuff Tested blood pressure in right arm with cuff Tested blood pressure in right arm with cuff Measured vitals why are you here today I have been having some troubling chest pain in my chest now and then for the past month. i am sorry you are experiencing that Thanks. I appreciate that. how much do you weigh in pounds As of this morning, a buck ninety-seven. can you rate your pain 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. when did the pain start I first noticed it earlier this month. I thought it might just be heartburn and it passed after about a couple of minutes. what aggravates your pain 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. what relieves your pain I'm not sure. I think lying still seems to help a little. where is your pain When the pain happens, I feel it mostly in the middle of my chest, over my heart. how long does your pain last When I feel it, it seems to get better over the course of a couple of minutes or so. describe your pain Well, it mostly feels tight and uncomfortable right in the middle of my chest. how are you treating your pain I haven't taken anything for the chest pain yet. What medications do you take Yeah, let's see, I take atorvastatin for cholesterol, metoprolol for blood pressure. . . Oh yeah, and I take fish oil too. I hear that's good for your cholesterol. [AUDIO COMING SOON] do you take any over the counter medicines Oh, just ibuprofen or Tylenol occasionally for pain. what dose of metoprolol do you take I think it's 100 mg, once a day. how long have you taken metoprolol I think it's been about one year. what is the dose for your cholesterol medicine ( It's 20 mg, once a day. (Clarified to what the dosage of my cholesterol medication is.) how long have you taken cholesterol medicine I think about a year. [AUDIO COMING SOON] how much ibuprofen do you take Just a couple when I get a headache, which is not very often. what is the dose of ibuprofen Just whatever the bottle recommends for an adult. when was the last time you took ibuprofen I don't recall. Been a few weeks at least. [AUDIO COMING SOON] how much tylenol do you take Just a couple when I get a headache, which is not very often. what dose of tylenol do you take Just whatever the bottle recommends for an adult. when was the last time you took tylenol I don't recall. Been a few weeks at least. [AUDIO COMING SOON] when was the last time you took your cholesterol medicine 3 months ago. why did you stop taking your cholesterol medicine Yes, I get it tested every couple of years. when was the last time you took your blood pressure pill I usually only get it checked when I visit the doctor. when did you last take metoprolol I think it's been about one year. what is your past medical history The doctors told me I have a little bit of high blood pressure and cholesterol, but that's it. do you smoke Nope, I had a lot of friends who did but I never started. are you exposed to second hand smoking Almost never. do you drink alcohol Sure, but never more than two or three beers on a weekend. what kind of alcohol do you drink Oh, mostly light beer, just a couple on the weekends. I'll have a bourbon with my son or on special occasions sometimes, too. do you do drugs Nope. do you smoke marijuana I'll put it this way: the last time I touched the stuff, Carter was in office. when did you last smoke marijuana I'll put it this way: the last time I touched the stuff, Carter was in office. tell me about your mom She has type 2 diabetes and some high blood pressure, but I think she's doing pretty well for 80. tell me about your dad (Clarified to Can you tell me about your father's health?.) He really wasn'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 didn't last too long after the cancer diagnosis, unfortunately. I think he was tired of fighting. (Clarified to how my dad's health was.) do you have siblings I have a sister, and I had a brother but he died many years ago. im sorry about your brother's death (No matching questions found.) im sorry about your brother's death Thanks. I appreciate that. tell me about your brothers health (No matching questions found.) tell me about your brother (No matching questions found.) how did your brother die It was a car accident. He was 24. tell me about your sister She has the same health problems as our mom. Diabetes and hypertension. how old is your sister She's fifty-two. tell me about your mom's dad My grandfather on my mom's side died of a heart attack. He was in his mid-fifties. tell me about your mom's mom She had breast cancer. She was in her 60s when she died. tell me about your dad's dad He was healthy right up until he died. He went in his sleep at 85, and we just called it old age. tell me about your dad's mom She died of pneumonia when she was almost 80. 78 or 79, I think. im sorry about your loss Thanks. I appreciate that. does anybody in your family have health problems (Clarified to Do you have a family history of psychiatric illness?.) Thankfully, no. (Clarified to if I have a family history of psychiatric illness.) tell me about any health problems in your family Well, my dad died of colon cancer, my mom and sister have diabetes . . . my daughter has asthma, we all have slightly high blood pressure, my mom's mom died of breast cancer, and my mom's dad died of a heart attack. do you have children Yes, I have two great kids. Well, they're not kids. Sam is 26 and Allie is 19. tell me about Allie (Clarified to Who is your daughter?.) My daughter's name is Allie. [AUDIO COMING SOON] (Clarified to who my daughter is.) does allie have health problems Allie's doing great. She has asthma, but she's got a handle on it. [AUDIO COMING SOON] does sam have any health problems Sam's health is wonderful. [AUDIO COMING SOON] is sam a boy or a girl Yep, my son Sam. And I have a daughter Allie. [AUDIO COMING SOON] tell me about your social history 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 she's home at least once a month. We try to have big family dinners when she's home. I go fishing with my friend Smitty and his brother every once in a while. are you married You bet. Happily married to my hot wife for, let's see, 27 years now. do you travel My wife and I went to Paris a couple years ago, but I haven't been anywhere else recently. do you go to church Usually only on holidays or when my mom is visiting. do you work I work at a civil engineering firm here in town. what do you do I'm an engineer. what is the name of the firm you work for Brian Robert Foster. are you up to date on your immunizations Yeah, I am. when did you last take the flu shot Well, I usually get the flu shot. I've had one in the past year. [AUDIO COMING SOON] it is important for you to take your flu shot early Good to know. Thank you. when was the last time you took a pneumonia vaccine I can't remember . . . I don't think so. have you had a tetanus shot I'm up to date on my tetanus shot. [AUDIO COMING SOON] when did you take your tetanus shot I'm up to date on my tetanus shot. [AUDIO COMING SOON] have you ever had surgery I've never had any surgeries. have you ever been hospitalized I've never had to go to the hospital, no. do you have a doctor Dr. Melinda Smith. when was the last time you saw dr smith (Clarified to When was your last doctor's visit?.) I had a physical about 3 months ago. (Clarified to when my last doctor's visit was.) do you have a cardiologist No, but I guess I might need one. you might need to have a cardiologist follow you since you have an extensive family history of cardiac problems and you are now experiencing chest pain Good to know. Thank you. when did you last go to the dentist Um . . . probably about a year ago. do you have a sexual preference I've only ever been attracted to women. Well, women and Paul Newman. does your chest pain radiate The pain doesn't radiate anywhere. It's mostly just right in the middle of my chest. do you have arm pain No, when I am having the chest pain, it's mostly just in middle of my chest. do you have shoulder pain No, the pain hasn't been in my shoulder. do you have back pain I haven't had back pain, no. do you have neck pain My neck's been fine. how often does your chest pain happen (Clarified to How often do you have chest pain?.) Well, it has happened three times the past month. It usually goes away after about a couple of minutes. (Clarified to how often have pain in your chest.) does your pain seem to be related to anything It seems like moving around makes it worse, or at least more noticeable. I felt a little better when I sat down to rest for a few minutes. do you have crushing pain (Clarified to Is the pain crushing?.) No, it's more tight and uncomfortable. (Clarified to if the pain is crushing.) is the pain gnawing No, it's not like that. [AUDIO COMING SOON] is the pain burning Not really. does your pain get worse when you eat (Clarified to Does eating anything make your pain worse?.) I don't think that has anything to do with it, but I guess I don't know. (Clarified to if eating makes the pain worse.) does the pain get worse with spicy foods I don't think spicy foods have anything to do with it. does the pain get worse with fatty foods (Clarified to Do certain foods make the pain worse?.) I don't think that has anything to do with it, but I guess I don't know. (Clarified to if certain foods make the pain worse.) do you eat a healthy diet Yeah, I think so. what do you eat daily Um, let's see . . . For breakfast I usually eat a granola bar and drink an instant breakfast shake. I've been doing that a while since it saves time in the morning. Most days for lunch I get a sandwich from the sub shop near work. That's usually a turkey sub, but sometimes I get a spicy Italian sub. My wife and I grill a lot, and usually have some grilled meat with veggies for dinner. do you take aspirin I usually just take Tylenol or ibuprofen. do you take fish oil That's right. what is the dose of your fish oil I take it daily. I think it's 1200 milligrams. how long have you taken fish oil (Clarified to Did you take fish oil today?.) Took it this morning. [AUDIO COMING SOON] (Clarified to if I took fish oil today.) when were you prescribed fish oil (No matching questions found.) why do you take fish oil (Clarified to How do you take fish oil?.) I take it daily. I think it's 1200 milligrams. (Clarified to how I take fish oil.) do you have any allergies No, well . . . I've had a bad reaction to codeine before, but that is all I know of. what happened when you took codeine When I took codeine a few years ago for my back, it made me pretty nauseous. I started throwing up and felt pretty terrible. [AUDIO COMING SOON] do you have any food allergies No, well . . . I've had a bad reaction to codeine before, but that is all I know of. do you have any environmental allergies No, well . . . I've had a bad reaction to codeine before, but that is all I know of. do you have diabetes No, I've avoided it but my mother and sister both have it. do you have heart disease Besides moderate hypertension and slightly elevated cholesterol, none that I know of. do you have coronary artery disease Not that I'm aware of. have you had any treatment for chest pain (Clarified to Have you ever had treatments for heart problems?.) Nothing other than blood pressure and cholesterol screenings. (Clarified to if I have been treated for heart problems.) how often do you check your blood pressure I usually only get it checked when I visit the doctor. do you remember having any abnormal blood pressure readings Yes, I supposedly have moderately high blood pressure. do you ever check your blood pressure at home Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it. have you ever seen a cardiologist I haven't seen a cardiologist -- this is the first time I'm telling anyone about this chest pain. [AUDIO COMING SOON] have you ever had an ekg I had one about three months ago. They usually put one on me at my annual physical. have you ever had a stress test Yes, I usually do one every year. was your ekg normal I don't remember the actual results, but as far as I know, it was normal. was your stress test normal I'm not sure, all the doctor ever tells me is, "everything looks good." how often do you see a doctor I see the doctor every 6 months unless there's something wrong in between. do you exercise Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven't had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I've been having. do you eat a lot of salt I'm not sure, I don't really pay attention to it. do you drink a lot of water I usually drink water all day at work. At least four glasses, probably more. [AUDIO COMING SOON] do you drink caffeine I drink a cup or two of coffee almost every day. Not much else. do you drink soda Once in a blue moon maybe. I avoid it 99% of the time. do you feel fatigued I'm not more tired than normal. do you feel stressed Not usually, but I'm feeling pretty anxious not knowing what's going on with my chest. do you have anxiety Not usually, but I'm feeling pretty anxious not knowing what's going on with my chest. do you have fever I haven't had a fever, no. do you have chills I haven't had chills, no. have you gained weight recently I've gained maybe 20 pounds over the last couple years. I guess I'm getting older . . . my wife doesn't seem to mind though! have you lost weight recently Not exactly . . . I've gained about fifteen to twenty pounds in the last couple years. do you have night sweats Nope, no night sweats. do you live in a clean home My wife and I own our house. do you have palpitations I don't think so. I haven't noticed any. do you have headache No, my head feels okay. do you have dizziness No, I haven't felt dizzy. what triggers your headaches (Clarified to What do your headaches feel like?.) Uh, well, I guess they feel like a dull ache. They're annoying, but not debilitating. (Clarified to what my headache pain feels like.) what relieves your headaches I usually just take Tylenol or ibuprofen. what makes your headaches worse I usually just take Tylenol or ibuprofen. what causes your headache Uh, well, I guess they feel like a dull ache. They're annoying, but not debilitating. do you have swelling I haven't noticed any swelling. do you have angina I've never been diagnosed with angina. [AUDIO COMING SOON] have you had a heart murmur No, none that I know of. have you had blood clots Not that I know of. have you had bleeding Not that I know of. do you have a cough I don't have a cough. any difficulty breathing My breathing's fine. Inspected face Inspected for jugular venous distension: No jugular venous distention; JVP 3 cm above sternal angle Inspected anterior chest wall Inspected left side chest wall Inspected anterior chest wall Inspected right side chest wall Inspected left side of abdomen Inspected front of abdomen Inspected right side of abdomen Inspected right hand: no visible abnormal findings Inspected left hand: no visible abnormal findings Inspected fingernails of left hand Inspected right hand: no visible abnormal findings Inspected left hand: no visible abnormal findings Inspected fingernails of right hand Inspected left leg Inspected right leg Inspected toenails on left foot Inspected toenails on right foot Inspected left leg Inspected right leg Inspected right leg for edema: No edema Inspected left leg for edema: No edema Checked capillary refill in fingernails Checked capillary refill in fingernails Checked capillary refill in fingernails Checked capillary refill in fingernails Checked capillary refill in fingernails Checked capillary refill in fingernails Checked capillary refill in fingernails Auscultated right carotid pulse: Bruit present Auscultated left carotid pulse Auscultated aortic area with the bell Auscultated aortic area with the diaphragm Auscultated pulmonic area with the diaphragm Auscultated Erb's point with the diaphragm Auscultated Erb's point with the bell Auscultated Erb's point with the diaphragm Auscultated tricuspid area with the diaphragm Auscultated mitral area with the diaphragm Auscultated aortic area with the bell Auscultated aortic area with the diaphragm Auscultated pulmonic area with the diaphragm Auscultated Erb's point with the diaphragm Auscultated tricuspid area with the diaphragm Auscultated mitral area with the diaphragm Auscultated mitral area with the bell Auscultated tricuspid area with the bell Auscultated Erb's point with the bell Auscultated pulmonic area with the bell Auscultated aortic area with the bell Auscultated breath sounds in anterior right upper lobe Auscultated breath sounds in anterior left upper lobe Auscultated breath sounds in anterior right middle lobe Auscultated breath sounds in anterior left mid-chest (upper lobe) Auscultated breath sounds in anterior right lower lobe Auscultated breath sounds in anterior left lower lobe Auscultated breath sounds in posterior left upper lobe Auscultated breath sounds in posterior right upper lobe Auscultated breath sounds in posterior left mid-back (lower lobe) Auscultated breath sounds in posterior right mid-back (lower lobe) Auscultated breath sounds in posterior left lower lobe Auscultated breath sounds in posterior right lower lobe Auscultated breath sounds in posterior left lower lobe on side Auscultated breath sounds in posterior right lower lobe on side Auscultated aorta in abdomen Auscultated aorta in abdomen Auscultated right renal pulse Auscultated left renal pulse Auscultated right iliac pulse Auscultated left iliac pulse Auscultated right femoral pulse Auscultated left femoral pulse Auscultated right upper quadrant Auscultated left upper quadrant Auscultated right lower quadrant Auscultated left lower quadrant Auscultated over liver Auscultated over spleen Palpated right carotid pulse: Thrill, 3+ Palpated left carotid pulse: No thrill, 2+ Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm Palpated right brachial pulse: No thrill, 2+ Palpated left brachial pulse: No thrill, 2+ Palpated right radial pulse: No thrill, 2+ Palpated left radial pulse: No thrill, 2+ Palpated right femoral pulse: No thrill, 2+ Palpated left femoral pulse: No thrill, 2+ Palpated right popliteal pulse: No thrill, 1+ Palpated left popliteal pulse: No thrill, 1+ Palpated right tibial pulse: No thrill, 1+ Palpated left tibial pulse: No thrill, 1+ Palpated right dorsalis pedis pulse: No thrill, 1+ Palpated left dorsalis pedis pulse: No thrill, 1+ Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Tested skin turgor Palpated for right kidney: Not palpable Palpated for left kidney: Not palpable Palpated for spleen: Not palpable Palpated liver: Palpable 1 cm below right costal margin Palpated right upper quadrant with deep pressure: No masses Palpated left upper quadrant with deep pressure: No masses Palpated right lower quadrant: with deep pressure: No masses Palpated left lower quadrant with deep pressure: No masses Percussed right upper quadrant Percussed left upper quadrant Percussed right lower quadrant Percussed left lower quadrant Percussed spleen Percussed for liver span: 7 cm in the mid-clavicular line Performed EKG how many medications do you take daily I'm taking cholesterol and blood pressure meds, yeah. do you take any other medications Just the atorvastatin and metaprolol. . . and sometimes ibuprofen when I need it. [AUDIO COMING SOON] do you take herbal medications I take fish oil, that's it. do you feel fatigue I'm not more tired than normal. do you feel weak I wouldn't say I feel weak. do you have trouble sleeping I usually sleep about 6 or 7 hours a night. do you have itching I haven't noticed anything weird with my skin, no. do you have redness I haven't had problems with my eyes like that. do you have nail discharge Not that I've noticed. any skin color changes My skin hasn't changed color on me. double vision I get my eyes checked every few years. So far, no glasses! eye pain I haven't had problems with my eyes like that. eye redness I haven't had problems with my eyes like that. vision changes I get my eyes checked every few years. So far, no glasses! vision changes I get my eyes checked every few years. So far, no glasses! photo phobia (No matching questions found.) do you have photo phobia (No matching questions found.) do you have photo-phobia (No matching questions found.) di your eyes hurt when exposed to light I haven't had problems with my eyes like that. eye discharge I haven't had problems with my eyes like that. earache No, my ears are fine. Tinnitus No, my ears are fine. Bleeding nose No, I sure don't think so. Vertigo (No matching questions found.) do you have Vertigo Thankfully, no. Have you had any hearing things has My hearing's fine. Have you had any hoarseness Nope. Have you had any oral ulcers (Clarified to Have you ever had oral lesions?.) Um . . . no. No problems with that. (Clarified to if I have had oral lesions.) Have you had a sore throat I haven't had a sore throat in a long time. Have you had congestion I haven't felt congested. All clear. [AUDIO COMING SOON] Have you had no discharge (No matching questions found.) Have you had post nasal drip (No matching questions found.) Have you had post nasal discharge (No matching questions found.) Have you had rhinorrhea (No matching questions found.) Have you had call (No matching questions found.) Have you had cough I don't have a cough. Hemoptysis (No matching questions found.) have you been coughing up blood No, definitely not. Can we have dyspnea (No matching questions found.) Can we have shortness of breath (Clarified to Do you currently have shortness of breath?.) My breathing's fine. (Clarified to if I have shortness of breath right now.) Any pain on inspiration No, not right now, but when I do it's tight and uncomfortable. I've experienced it three times this month. Are you producing sputum I don't have a cough. Do you have phlegm I don't have a cough. Any numbness Nope, I haven't noticed anything. Anything Lane (No matching questions found.) any tingling Nope, I haven't noticed anything. Have you passed out [Show More]

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