CARDIAC ASSESSMENT
HEART & PERIPHERAL VESSELS
Pt. Initials: J.S
Gender: F
Age: 26
Date: 9/19/17
S: CC: “Chest Pain”
HPI: Mrs. S is a 26-y-o white female with history of HTN who presents
today with c/o ”chest pain” that began while shoveling the driveway 3
hours ago and has been persistent since. States she has never
experienced this pain before. Describes pain as a heavy pressure to
sternal area and rates pain 6/10 currently. Rest improves the pain and
exertion causes it to worsen. No change in pattern of pain since it
started. Denies SOB, radiation to arm, neck, back or jaw. Uses 2
pillows to sleep in supine position at night.
PMH: HTN x3 years. Currently takes 10 mg Lisinopril and 81 mg aspirin
daily.
SH: 7 beers/week. Endorses 1 PPD for 20 years, trying to quit. Denies
any h/o drug use. Works as registered nurse in hospital setting, denies
any new or worsening stress in job. Married for 5 years. Diet consists
of low carb, low fat diet and has been walking at least 30 min 3-4 time
per week for 1 year.
FH: Maternal Grandmother: HTN-2000, living 81
Maternal Grandfather: 2 stents 2007, CHF-2005, AF-2007, living 82
Paternal Grandfather: Triple bypass-2002, deceased MI at 80
Paternal Grandmother: No history, living 80
Mother: No history, 51
Father: HTN, Hypercholesterolemia 2015, living 57
ROS: Denies h/o DM, CAD, COPD, MI, recent surgeries. Denies fever.
Denies SOB currently.
Cardiac: C/o chest heaviness (see HPI), endorses dyspnea on exertion,
denies edema, dizziness, emesis, palpitations or orthopnea. Last ECG
10 years ago, NSR.
Lung: Intermittent dry cough off and on for 1 year, denies hemoptysis,
endorses dyspnea on exertion.
Skin/nails: Denies cyanosis, clubbing of fingers, and
numbness/tingling sensation.
O:26-y-o white female in NAD, BP 128/82, HR 88, RR 18 full & easy.
Wt- 146, Ht- 5’5” BMI- 24.9, cooperative, pleasant, dressed
appropriately and good historian.
HEART & PERIPHERAL VESSELS
Pt. Initials: J.S
Gender: F
Age: 26
Date: 9/19/17
S: CC: “Chest Pain”
HPI: Mrs. S is a 26-y-o white female with history of HTN who presents
today with c/o ”chest pain” that began while shoveling the driveway 3
hours ago and has been persistent since. States she has never
experienced this pain before. Describes pain as a heavy pressure to
sternal area and rates pain 6/10 currently. Rest improves the pain and
exertion causes it to worsen. No change in pattern of pain since it
started. Denies SOB, radiation to arm, neck, back or jaw. Uses 2
pillows to sleep in supine position at night.
PMH: HTN x3 years. Currently takes 10 mg Lisinopril and 81 mg aspirin
daily.
SH: 7 beers/week. Endorses 1 PPD for 20 years, trying to quit. Denies
any h/o drug use. Works as registered nurse in hospital setting, denies
any new or worsening stress in job. Married for 5 years. Diet consists
of low carb, low fat diet and has been walking at least 30 min 3-4 time
per week for 1 year.
FH: Maternal Grandmother: HTN-2000, living 81
Maternal Grandfather: 2 stents 2007, CHF-2005, AF-2007, living 82
Paternal Grandfather: Triple bypass-2002, deceased MI at 80
Paternal Grandmother: No history, living 80
Mother: No history, 51
Father: HTN, Hypercholesterolemia 2015, living 57
ROS: Denies h/o DM, CAD, COPD, MI, recent surgeries. Denies fever.
Denies SOB currently.
Cardiac: C/o chest heaviness (see HPI), endorses dyspnea on exertion,
denies edema, dizziness, emesis, palpitations or orthopnea. Last ECG
10 years ago, NSR.
Lung: Intermittent dry cough off and on for 1 year, denies hemoptysis,
endorses dyspnea on exertion.
Skin/nails: Denies cyanosis, clubbing of fingers, and
numbness/tingling sensation.
O:26-y-o white female in NAD, BP 128/82, HR 88, RR 18 full & easy.
Wt- 146, Ht- 5’5” BMI- 24.9, cooperative, pleasant, dressed
appropriately and good historian.
