cardiac soap note.docx - Subjective Chief complaint Chest pain for one month onset one month ago location mid sternal duration three times over the past

cardiac soap note.docx - Subjective Chief complaint Chest...

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Subjective Chief complaint: Chest pain for one month. onset: one month ago location: mid sternal duration: three times over the past month and subsides after a couple of minutes. Characteristics: tightness and discomfort in the middle of the chest 5/10 when it occurs aggravating factors: physical exertion worsens the pain relieving factors: rest treatment: none reported Current medications: lopressor 100mg po daily lipitor 20mg po daily at hs last dose last night at 2200 omega 3 fiish oil 1200mg po bid last dose at 0800 this morning. allergies: Codeine causes nausea and vomiting past medical history: hypertension stage 2 diagnosed 1 year ago Hyperlipidemia diagnosed 1 year ago Surgical history: denies Tdap 2014 Flu vaccine this year Social history: patient is an engineer works at a civil engineering firm in town. Patient states he deals with stress by fishing. Patient states he has not had much regular exercise since his bike was stolen two years ago. Patient states he attempts to moderate fat and carbohydrates but he does eat red meat intermittently. Patient states he drinks approximately 1 liter of water a day at work. Patient denies tobacco use. Patient states drinks about two beers a week on Sunday when grilling. Patient denies illicit drug use. Patient reports 100% use of seatbelt when driving Family history: father had hypertension hyperlipidemia obesity died of colon cancer at age 75. Mother had type two diabetes hypertension she is 80 y/o Brother died age 24 in a motor vehicle accident Sister has Type 2 diabetes hypertension age 52 Maternal grandmother died of breast cancer age 65 Maternal grandfather died of heart attack age 54 Paternal grandmother died of pneumonia age 78 Paternal grandfather died of "old age" 85 Son is healthy age 26 Daughter: asthma age 19 Review of systems: Constitutional: patient denies weight loss, fever, chills, weakness or fatigue HEENT: patient denies visual loss, blurred vision, double vision. Patient denies hearing loss, sneezing,
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  • Fall '15
  • Common carotid artery, pulse

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