OrthopneaPolyuria Female Reprod.HematologicChng VoicexPalpitationsScrotal Masses/Pain Abnormal MensesAnemiaDenturesPNDSTD’s DrynessEasy BruisabilityEpistaxisGastrointestinalUrgency DyspareuniaEnlarged LN’sHoarsenessBRBPRSexual AbuseHxTransfusionsSinusitisChng Bowel HabitsVaginal DischargeComments:CC: ____Chest pain ___Persistent and unremitting substernal chest pain______________________________________________________________________________________________________________________________________________________________________________ Initial:__6 hours ago_________________________HPI: (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Assoc. Signs/Symptoms)____Chest pain of central location with radiation to the left arm and jaw. Quality of a severe chest pain Severe enough to prevent patient mobilization and requiring analgesics and morphine. The timing refers to the last 6 hours of continuous chest pain. Context. It happened atthe dinner table at lunch time. Modifying factors. None. Only lying down provides some relief to the patient. Associated signs and symptoms. SignsPersistent pain with sharp or knife pain characteristics with radiation to left arm down to the index finger and the jaw and throat. Patient is sweeting and abdominal pain in the epigastrium area. He is not able to talk or complain for the last couple of hours.Symptoms. Mild fever, lightheadedness, mild confusion, shortness of breath, hypotensive and showing signs of starting to loose consciousness ___________________________________________________________________________________________________________________Medical assessment from the Professional Nursing care documentation Department in Acute Care _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PMH Reviewed – No Changes; See Adult Summary FormPMH Reviewed & Updated; See Adult Summary FormSHx Reviewed – No Changes; See Extended Hx FormSHx Reviewed & Updated; See Extended Hx FormFHx Reviewed – No Changes; See Extended Hx FormFHx Reviewed & Updated; See Extended Hx FormVital Signs:Age: ____________Weight: _310___________BMI: __39.8___________Temperature: ___100.7__________Blood Pressure: _100/45________not discernible_____Pulse: _______________Respirations: _28_______ Fingerstick: _____________ LMP: _____________ Oxygen Saturation: __87_____________ Initials: _________Physical Exam:Nl Ab GeneralNl AbNl AbNl AbNl Ab MSKx Appearancex AuscultationxxBowel SoundsAxillaryInspectionVSx PercussionPalpation InguinalExam of Joint
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