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NURS5342 Advanced Health Assessment
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CC: 49-year-old female Chief complaint is a short 1-2 statement or word phrase from patient and should be listed in “quotes” “Exertional mid-chest pain that radiates to left arm with a squee... zing quality” HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts Ms. Barnes is a 49-year-old female with chest pain and dyspnea that started 2 weeks ago during a ski run activity in the cold. She reports that the chest pain radiates to the left arm and has a squeezing quality to it. The pain is exacerbated by fast walking in the cold and relieved by resting. Onset: Chest pain 2 week ago during a cross-country ski run Location: Mid chest that radiates to left arm Duration: The chest pain comes and goes. Lasts several minutes and occurs1-2 times a week Character: Chest pain with a squeezy quality and radiates to the left arm. Pain scale of 5 or 6 on scale of 1-10 Aggravating/alleviating factors: Precipitated by exercise and improves with rest Related symptoms: Dyspnea that occurs with chest pain with exertion Treatments: Nothing Significance: Chest pain in someone with her medical and family history can indicate a serious problem PMHx child/adult illness/hospitalizations/immunizations History of hypertension and high cholesterol Missed this year’s flu vaccination SurgHx type/when/why/complications No surgical history [Show More]
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