6512N Wk7Assign1.docx - Document Provider Notes u2013 NURS...

Name:
Focused Exam: Chest Pain
Subjective
Mr. Brian Foster
Chief Complaint: “I have been having some troubling chest pain in my chest now and then for the past month”
History of Present Illness: Mr. Foster is a 58 years old Caucasian male, complaining of intermittent chest pain
lasting for couple minutes. Patient thought at first that it was heartburn, and added that his chest pain started a
month ago and mostly feels tight and uncomfortable right in the middle of his chest. Mr. Foster first experience
the chest pain during yard work, and the second time happen while climbing the stairs. Patient states that the
pain does not radiated subsided at rest. Patient denies shortness of breath, no nausea, no dizziness, no previous
history of syncope. Denies pain at the moment.
Current Medications:
 Metoprolol 100 mg po daily
 Atorvastatin 20 mg po daily at bedtime last dose last night at 10pm
 Over the counter supplement: Omega-3 Fish oil 1200 mg po twice a day, last dose this morning at 8:00
Allergies: Codeine experience nausea and vomiting
Immunization: Tdap in October 2014
 Influenza vaccine this seasonPast Medical History:
 Hypertension. diagnosed a year ago
 Hyperlipidemia, diagnosed at one year ago
 No surgical history
 no hospitalization
Family History:
 Father had hypertension, hyperlipidemia, obesity, and Died of colon cancer at the age of 75
 Mother is 80 years old, has Type II diabetes, hypertension
 Brother died at the age 24 from motor vehicle accident
