Focused Exam: Chest Pain Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Document: Vitals 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.
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Self-Reflection
Documentation / Electronic Health Record
https://www.coursehero.com/file/31240636/Focused-Exam-Chest-Pain-DOCUMENTATIONpdf/
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