wk7DCEassignpost.docx - Student Documentation Model...

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.