Brian Foster_ Wk7_DCE .docx - Document Provider Notes \u2013 NURS 6512 Name Chest Pain \u2013 NURS 6512 Oct 2020 Focused Exam Chest Pain C o p y r i g h t \u00a9

Brian Foster_ Wk7_DCE .docx - Document Provider Notes...

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Name: Focused Exam: Chest Pain Chest Pain – NURS 6512 Oct 2020 Document: Provider Notes – NURS 6512 Copyright © 2019 || Shadowhealth.com 1
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Subjective Subjective Chief Complaint: “I’ve been experiencing this tight, uncomfortable feeling in my chest every now and then.” With concerns that this chest pain could be serious. History of Present Illness: Mr. Foster is a 58-year-old Caucasian male presenting in the ED with complaints of chest. The onset was “earlier this month.” Description of pain is “tight and uncomfortable in the middle of the chest.” Patient initially contributed the pain as heartburn but was unsure. Denies taking medication for the pain. Patient goes on to say the pain last for a couple of minutes then subsides. Rating the pain at the time pain was 5/10. Currently, the patient states pain is 0/10. The patient explains that the pain arises on exertion. First, while doing yard work and the second was walking up the stairs at work. Rest alleviates the pain. Denies previous episodes of chest pain. Denies other ailments at this time. Medication: o Atorvastatin 20mg PO daily at HS for Hyperlipidemia. Last dose yesterday at 10pm o Lisinopril 20 mg PO daily for Hypertension. Last dose today. o Omega 3 Fish Oil capsule 1200mg BID as a supplement. Last dose 8am Allergies: o Codeine – Nausea and vomiting Immunization: o Tdap – 10/2014 o Influenza vaccine this season Medical History: o Hypertension – Stage II, diagnosed 1 year ago. o Hyperlipidemia – Diagnosed 1 year ago. o No other medical issues/ No surgical history. o Last physician (Dr. Melinda Smith) visit was 3 months ago. (Regular visit every 6 months).
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