Doctura_Nancy_Wk7_DCE.docx - Document Provider Notes \u2013 NURS 6512 Name Nancy Doctura Focused Exam Chest Pain C o p y r i g h t \u00a9 2 0 1 9 | S h a d o w

Doctura_Nancy_Wk7_DCE.docx - Document Provider Notes u2013...

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Name: Focused Exam: Chest Pain Nancy Doctura Document: Provider Notes – NURS 6512 Copyright © 2019 || Shadowhealth.com 1
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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
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