Brian Foster Chest pain
Chief Complaint
e Established chief complaint
o Do you have chest pain?
History of Present lliness
e Asked about onset of pain
o When did your chest pain start?
e Asked about location of pain
o Where is the pain?
Does the pain radiate?
0O
Are you experiencing arm pain?
Are you experiencing shoulder pain?
0
Are you experiencing back pain?
o
o Are you experiencing neck pain?
e Asked about duration of pain episodes
o How long does your chest pain last?
e Asked about frequency of pain
o How many times in the last month have you had chest pain?
o Did the episodes seem associated?
r LA U T W IOUWELD Il T oo LT .
e Asked about severity of pain
o How would you rate your pain on a scale of zero to ten?
e Asked about characteristics of pain
o Can you describe your pain?
o Isthe pain crushing?
o Isthe pain gnawing?
o Isthe pain burning?
e Asked about aggravating factors
o What makes the pain worse?
o What activity triggered the pain?
o Isthe pain worse when you eat?
o Isthe pain worse after you eat spicy food?
o Isthe pain worse after you eat high-fat foods?
e Asked about relieving factors
o What relieves your pain?
o Did you take anything for the chest pain?
Past Medical History
e Confirmed allergies
o Do you have new allergies?
e Asked about related medical conditions
o Do vou have a historv of angina?
, Do you have high blood pressure?
oo
Do you have high cholesterol?
o Do you have coronary artery disease?
Do you have diabetes?
o
0 Have you had previous treatment for chest pain?
* Asked about blood pressure monitoring
0 How often do you measure your blood pressure?
o When do you measure your blood pressure?
o What is your typical blood pressure reading?
* Asked about past cardiac tests
o Have you recently had an EKG?
0 Have you recently had a stress test?
* Followed up on results of cardiac tests
0 What were the results of your last EKG?
0 What were the results of your last stress test?
Home Medications
o Asked about home medications
0 Do you take medication for high blood pressure?
o Do you take medication for high cholesterol?
o Do you take over the counter medications?
o Do you take any supplements?
o Do you take aspirin?
* Followed up on high blood pressure medication
0 What medication do you take for high blood pressure?
0 What dose of medication do you take for high blood pressure?
o How frequently do you take medication for high blood pressure?
* Followed up on high cholesterol medication
0 What medication do you take for high cholesterol?
What dose of medication do you take for high cholesterol?
coo o
How frequently do you take medication for high cholesterol?
What time of day do you take your high cholesterol medication?
How long have you taken cholesterol medication?
, Social Determinants of Health
* Asked about access to healthcare
o Do you have a primary care provider?
‘When was your last visit to a healthcare provider?
o oo o
How often do you see a healthcare provider?
Do you have difficulty accessing healthcare because of transportation?
Do you have trouble affording healthcare?
Social History
* Asked about stress
0 What is your stress level?
* Asked about exercise
0 What kind of exercise do you get?
0 When did you last exercise regularly?
* Asked about typical diet
0 What s a typical breakfast for you?
0 What s a typical lunch for you?
0 What is a typical dinner for you?
o Do you moderate your salt intake?
* Asked about fluid intake
o Do you drink water every day?
0 How much coffee do you drink per day?
0 How much soda do you drink per day?
¢ Asked about substance use
o Do you use illicit drugs?
o Do you use tobacco?
o Do you consume alcohol?
* Followed up on alcohol consumption
o Do you drink alcohol?
0 How many alcoholic drinks do you have in one sitting?
0 When do you drink alcohol?
Chief Complaint
e Established chief complaint
o Do you have chest pain?
History of Present lliness
e Asked about onset of pain
o When did your chest pain start?
e Asked about location of pain
o Where is the pain?
Does the pain radiate?
0O
Are you experiencing arm pain?
Are you experiencing shoulder pain?
0
Are you experiencing back pain?
o
o Are you experiencing neck pain?
e Asked about duration of pain episodes
o How long does your chest pain last?
e Asked about frequency of pain
o How many times in the last month have you had chest pain?
o Did the episodes seem associated?
r LA U T W IOUWELD Il T oo LT .
e Asked about severity of pain
o How would you rate your pain on a scale of zero to ten?
e Asked about characteristics of pain
o Can you describe your pain?
o Isthe pain crushing?
o Isthe pain gnawing?
o Isthe pain burning?
e Asked about aggravating factors
o What makes the pain worse?
o What activity triggered the pain?
o Isthe pain worse when you eat?
o Isthe pain worse after you eat spicy food?
o Isthe pain worse after you eat high-fat foods?
e Asked about relieving factors
o What relieves your pain?
o Did you take anything for the chest pain?
Past Medical History
e Confirmed allergies
o Do you have new allergies?
e Asked about related medical conditions
o Do vou have a historv of angina?
, Do you have high blood pressure?
oo
Do you have high cholesterol?
o Do you have coronary artery disease?
Do you have diabetes?
o
0 Have you had previous treatment for chest pain?
* Asked about blood pressure monitoring
0 How often do you measure your blood pressure?
o When do you measure your blood pressure?
o What is your typical blood pressure reading?
* Asked about past cardiac tests
o Have you recently had an EKG?
0 Have you recently had a stress test?
* Followed up on results of cardiac tests
0 What were the results of your last EKG?
0 What were the results of your last stress test?
Home Medications
o Asked about home medications
0 Do you take medication for high blood pressure?
o Do you take medication for high cholesterol?
o Do you take over the counter medications?
o Do you take any supplements?
o Do you take aspirin?
* Followed up on high blood pressure medication
0 What medication do you take for high blood pressure?
0 What dose of medication do you take for high blood pressure?
o How frequently do you take medication for high blood pressure?
* Followed up on high cholesterol medication
0 What medication do you take for high cholesterol?
What dose of medication do you take for high cholesterol?
coo o
How frequently do you take medication for high cholesterol?
What time of day do you take your high cholesterol medication?
How long have you taken cholesterol medication?
, Social Determinants of Health
* Asked about access to healthcare
o Do you have a primary care provider?
‘When was your last visit to a healthcare provider?
o oo o
How often do you see a healthcare provider?
Do you have difficulty accessing healthcare because of transportation?
Do you have trouble affording healthcare?
Social History
* Asked about stress
0 What is your stress level?
* Asked about exercise
0 What kind of exercise do you get?
0 When did you last exercise regularly?
* Asked about typical diet
0 What s a typical breakfast for you?
0 What s a typical lunch for you?
0 What is a typical dinner for you?
o Do you moderate your salt intake?
* Asked about fluid intake
o Do you drink water every day?
0 How much coffee do you drink per day?
0 How much soda do you drink per day?
¢ Asked about substance use
o Do you use illicit drugs?
o Do you use tobacco?
o Do you consume alcohol?
* Followed up on alcohol consumption
o Do you drink alcohol?
0 How many alcoholic drinks do you have in one sitting?
0 When do you drink alcohol?
