NR509 Focused Exam: Chest Pain Results

NR509 Focused Exam: Chest Pain Results | Turned In

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Advanced Health Assessment – Chamberlain, NR509-April Return to Assignment

Your Results Lab Pass

 

 

Documentation / Electronic Health Record

Document: Provider Notes

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.

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NR509 Focused Exam: Chest Pain

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