Nr 509 Focused Exam Chest Pain Completed Shadow Health Turned In Advanced Health Assessment (Nr509)

Exam (elaborations) NR 509 FOCUSED EXAM CHEST PAIN COMPLETED SHADOW HEALTH TURNED IN ADVANCED HEALTH ASSESSMENT (NR509) Document: Provider Notes Student Documentation Model Documentation Subjective Patient information Brian Foster date of birth August 17th, a 58 year old Caucasian male CC: mr. Foster States" I have been having some troubling chest pain in my chest now and then for the past month." HPI: VS: b/p (L) ARM 146/88 mmhg (R) arm 146/90 mmhg MAP 109mmhg HR 109 BPM RR- 19 O2 Sat 98% RA Temp: 36.7 C (98 F) Onset of chest pain one month ago, lasting " few min" pt states, "thought it may be heart burn" reports Tight and uncomfortable right in the middle of the chest. Denies any pain radiating denies any arm pain shoulder pain back pain or neck pain. Pain only last a few minutes. An uncomfortable feeling that lasts a few minutes reporting 3 episodes in the past month and all feels the same. Pain currently a zero when having chest pain is 5 out of 10 on pain scale. Patient describes pain as tight and uncomfortable. Patient denies crushing or burning pain to the chest. Laying down seems to alleviate the pain with a brief rest. Not taking any medications for chest pain. Episodes of chest pain started with physical activity while doing yard work Pt. reports "I have been having some troubling chest pain in my chest now and then for the past month." Experiencing periodic chest pain with exertion such as yard work as well as with overeating. Points to midsternum as location. Describes pain as “tight and uncomfortable.” Denies radiation. Pain lasts for “a few” minutes and goes away when he rests. Most recent episode was three days ago after eating a large restaurant dinner. States “It has never gotten ‘really bad’” so didn’t think it was an emergency, but is concerned after three episodes in one month and wants his heart checked out. Reports mild cramping in legs with activity. Denies shortness of breath, indigestion, heartburn. Denies chest pain at this time. Focused Exam: Chest Pain | Completed | Shadow Health Student Documentation Model Documentation in the second episode was taking stairs at work denies any pain with food. Patient confirms all medications are still current and unchanged. No new allergies noted. Confirms hypertension diagnosis and hyperlipidemia diagnosis denies any angina coronary artery disease or previous chest pain treatments. Patient does not check blood pressure on a regular basis only windows to the doctor states doctor does not seem concerned about his blood pressure Current medications: metoprolol 100 mg one po q day, atorvastatin 20 mg po q day, last dose 10 p.m. yesterday ( hyperlipidemia), omega-3 fish oil 1200mg one po q day last dose, Thursday 8 a.m. over the counter. Denies any aspirin use but takes Tylenol or Motrin when having a headache denies headache are not very often. Report heavy EKG before and stresses both normal lasts all primary care doctors 3mmonths ago. see's pcp every 6months. Allergies: codiene ( n/v) PMHx: hypertension stage 2 diagnosed 1 year ago, hyperlipidemia diagnosed 1 year ago. Denies any surgeries. Influenza uptodate, TDAP 10/2014 Soc Hx: denies any illicit drug use or tobacco use. Patient does report drinks 2 to 3. No unusual stress noted. alcoholic beverages per week (beer) no regular exercise last regular exercise he was 2 years ago. Diet consist of granola bars turkey subs and grilled meat and veggies. Unsure of salt intake. Reports drinking a one liter of water a day. drinks coffee one to two a day . denies illegal drugs and comfirmed alcohol intake. Fam Hx: father- hypertension hyperlipidemia obesity, deceased at age 75 of colon cancer mother- type 2 diabetes and hypertension 80 brother- disease at age 24 MVA sister- type 2 diabetes and hypertension age 52 maternal grandfather- by the age 54 of a heart attack maternal grandmother- died of breast cancer at age 65 paternal grandmother- died of pneumonia at age 78 paternal grandfather- disease at 85 years old"old age" son - healthy age 26 daugther - asthma age 19 ROSGeneral: denies any fatigue increased sweating fever or recent illness skin no rashes or lesions or skin changes No reports of sore throat or difficulty swallowing no shortness of breath. ROS WNL confirmed family history no changes