Document: Nursing Notes
Mr. Foster is post-op day 3 for a TURP (Transurethral resection of the
prostate). He is complaining of chest pain that began 5 minutes ago. He
rates his pain at 6/10. He reports the pain is localized to the sub-sternal
region and describes it as “squeezing pressure.” He reports the pain is
constant and increasing in severity. He denies radiation but reports some
pressure in the left shoulder as well. He reports the pain was
accompanied by nausea at the onset, but denies emesis. The patient
reports becoming increasingly anxious. He denies SOB and palpitations.
He denies tenderness, redness, or changes in surgical site.
• General Survey: Alert, but uncomfortable appearing middle-aged male
supine in hospital bed, pale and mildly diaphoretic. Elevated respiratory
rate and evident distress. • Cardiovascular: No JVD, HR between 100-
115, S1 & S2, + S4. No murmur, no rub. Occasional PVCs appreciated.
BP range 92-109/57-68. No carotid bruit or thrill. • Peripheral Vascular:
Capillary refill <3 seconds on bilateral fingers and toes, radial pulses 2+,
posterior tibial and dorsalis pedis pulses +1. No lower extremity edema.
No varicosities, no areas of focal induration or erythema. • Respiratory:
Respirations quiet and unlabored, able to speak in full sentences. Lungs
CTA. RR 24-26/m, O2 saturation 97-99%. • Neuro: Alert and oriented x3,
follows commands, moves all extremities. • Skin: Diaphoresis. No pallor,
redness, induration, or purulence noted. • EKG (interpretation): Sinus
tachycardia with occasional PVCs. No ST segment elevation.