Name:
Focused Exam: Chest Pain
Chekita Haley
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Shadow Health Documentation Template - Focused Exam_Chest_Pain - NURS 6512”
Document: Provider Notes – NURS 6512
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Shadowhealth.com
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CC: "I have been having troubling chest pain now and then for the past month."
HPI: Brain Foster is a 58 year old white male who complains of chest pain that comes and goes in the
middle of his chest that goes away after a couple of minutes. He states his pain feels like a tightness that
causes his anxiety level to increase when the pain is worst. He describes the pain to be a 5 out of 10 but
currently a zero. He states his chest pain seems worse with physical activity. He states he has had three
episodes of chest pain with tightness.The first time was after he was working in the yard. The second onset
of pain occurred after walking up stairs due to the elevator being broke at work. He states lying still helps
alleviates his pain.
Health History: diagnosed with hypertension and high cholesterol last year. up to date on immunizations,
influenza vaccine last received last year, no history of pneumonia vaccine. last tetanus 10/2014. no history of
hospitalizations. last physical was about 3 months ago. last EKG was 3 months ago with normal results.
Surgical Hisotry: denies surgical history
Allergies: codeine (casues nausea and vomiting)
Medications: Atorvastatin 20mg once daily, Metoprolol 100mg once daily, Fish Oil 1200mg daily, Ibuprofen
over the counter prn for pain, and
tyelonol over the counter prn for pain
Social Hx: lives with his 51 year old wife and occassionally his 19 year old daughter is lives in his home at
least once month. reports has a 26 year son who lives in town as well. Mr Fostrer works at a civil engineering
