wk7DCEassignpost.docx - Student Documentation Model Documentation Subjective N\/A CC Chest Pain HPI 58-year-old Caucasian male who reports tight

wk7DCEassignpost.docx - Student Documentation Model...

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Student Documentation Model Documentation Subjective CC : Chest Pain HPI : 58-year-old Caucasian male who reports tight, intermittent chest pain in the center of chest three times in the last month. with pain and tightness lasting several minutes. pt. reports chest pain comes with physical exertion performing yard work or climbing stairs patient denies any other symptoms no radiating pain. Medication: Metoprolol 100 mg daily, Atorvastatin 20 mg daily OTC Omega 3 fish oil 1200mg PO BID occasional Ibuprofen and Tylenol Allergies : codeine- Nausea and vomiting PMH : Hypertension x 1year (stage II), does not monitor blood pressures at home, Hyperlipidemia x 1 year. no past surgeries Vaccination- up to date Family History : Father died of colon cancer, Hx HTN, hyperlipidemia, Mother-HTN, DM2, Sister HTN, DM2, Maternal GF-Heart Attack, paternal Grandmother: died of pneumonia Social History : Married 28 years with 2 adult children, denies tobacco use, alcohol 2-3 beers on weekends, denies drug use, denies exercise, drinks 1-2 cups of coffee daily.
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