Name:
Focused Exam: Chest Pain
Nancy Doctura
Document: Provider Notes – NURS 6512
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Shadowhealth.com
1
Subjective
Subjective
Chief Complaint: Chest Pain
History of Present Illness: Brian Foster is a 58-year-old White male who came in complaining of
chest pain that started earlier this month. Pain described as tight and uncomfortable in the middle of
the chest. Patient reported that he thought it was a heartburn. Chest pain lasted for a couple of
minutes and was non-radiating. Patient reports having 3 episodes of chest pain in the past month.
Reports pain level is currently 0 out of 10 but rates pain at 5 out of 10 at its worst. Pain is
aggravated by physical activity. Pain occurred while doing yard work and using stairs. Pain gets
better with rest. Patient denies taking medication for the pain. Patient denies any other
accompanying symptoms. Patient has not had prior evaluation of chest pain.
Medications: Metoprolol 100 mg PO daily
Atorvastatin 20 mg PO daily at bedtime
Omega 3 Fish Oil 1200 mg PO BID
Ibuprofen PRN occasionally for headache
Tylenol PRN for mild pain. last dose today.
Allergies: Codeine causes nausea and vomiting
Past Medical History:
Hypertension, Stage 2, diagnosed a year ago
Hyperlipidemia- diagnosed a year ago
Denies any surgery.
Denies history of hospitalization.
Immunization: Tdap 10/2014, Flu vaccine up to date
Family History:
Father: Hypertension, Hyperlipidemia, Obesity, died of colon cancer at age 75
Mother: Type 2 Diabetes, Hypertension, age 80
Sister: Type 2 Diabetes, Hypertension, age 52
Brother: Died in a car accident at age 24
Maternal grandmother: Died of Breast Cancer at age 65
Maternal grandfather: Died of a Heart Attack at age 54
Paternal Grandmother: Died of Pneumonia at age 78
Paternal Grandfather: Died of "old age" at age 85
Son: Healthy, age 26
Daughter: Asthma, Age 19
Personal and Social History:
Denies taking illicit drugs
