WEEK 7 DOCUMENTATION.docx - Document Provider Notes\u2013 NURS 6512 Name Titilayo Ilori Focused Exam Chest Pain Type your narrative-style documentation for

WEEK 7 DOCUMENTATION.docx - Document Provider Notesu2013...

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Document: Provider Notes– NURS 6512 Copyright © 2019 || Shadowhealth.com Name: Focused Exam: Chest Pain Subjective Patient initials, Brain Foster., a 58 year old Caucasian Mle CC: “I have been having some troubling chest pain in my chest now and then for the past month” HPI: Mr. Foster is a 58 year old Caucasian Male who reports episodes of chest pain in the last month. The pain felt like heartburn, and lasted only a couple of minutes. He describes that pain as a feeling of tightness and being uncomfortable. He said that the pain came suddenly and is in the center of his chest but does not radiate. He rated the pain as 5 on the scale of 0-10, but currently was 0. He denies cough, nausea, diarrhea, and shortness of breath. Resting helps to relief the pain. Current Medications: Metoprolol 100mgPO daily for hypertension, Atorvastatin 20mg PO daily, Omega 3-fish oil 1200mg PO BID for high cholesterol. Allergies: Codeine: Causes nausea and vomiting PMH: No surgical history. Stage II high blood pressure diagnosed one year ago, high cholesterol also diagnosed one year ago Soc Hx : Takes 2-3 alcoholic beverages a week. No past or present history of tobacco use. Denies history of illicit drugs Family history: His father passed away at the age of 75 from colon cancer. Before His death, the father had hyperlipidemia, obesity, hypertension, and colon cancer. His mother is 80 years old with
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