Focused Note Chest Pain - Brian Foster| Latest Update (Verified ) 2020

Focused Note Chest Pain - Brian Foster Necessary Components for the Subjective information: Patient Name or initials: Brian Foster Informant: (Source of history/Reliability) The informant is the patient, seems reliab ...

Focused Note Chest Pain - Brian Foster Necessary Components for the Subjective information: Patient Name or initials: Brian Foster Informant: (Source of history/Reliability) The informant is the patient, seems reliable. Chief Complaint (CC): “I have been having some troubling chest pain in my chest now and then for the past month.” History of present illness (HPI): Mr. Foster is a 58 year old Caucasian male with a PMH of HTN and HLD who presents to the clinic with a chief complaint of chest pain described as tight, uncomfortable, non-radiating, midsternal chest pain rating 5/10 occurring three times in the last month lasting only a “couple of minutes”. The first occurrence was with yard work, the second occurrence was after walking up four flights of stairs at work, and the third occurrence was while out to dinner with his wife. The pain is worsened and more noticeable with movement and is relieved by rest. He denies taking any medication for the chest pain. He denies any current pain. He denies any shortness of breath, nausea, vomiting, diaphoresis, or dizziness. Allergies: Codeine (reports nausea and vomiting), denies food, environment, or latex allergy Medications: - Metoprolol (Lopressor) 100mg PO daily, last dose 0800 – (taken for HTN, prescribed for 1 year) - Atorvastatin (Lipitor) 20mg PO daily at bedtime, last dose 2200 yesterday – (taken for HLD, prescribed for 1 year) - Omega-3 Fish Oil 1200mg PO BID, last dose 0800 – (OTC supplement for HLD) - Ibuprofen PRN (per directions on bottle for various aches and pains, no more than 3 or 4 times monthly) Past History: Denies childhood illnesses, HTN Stage II diagnosed 1 year ago, HLD diagnosed 1 year ago, Denies surgical history Family History: : Father: deceased age 75 from colon cancer, hx HTN, HLD, obesity Mother: living age 80, hx T2DM, HTN, Brother: deceased age 24 from MVA Sister: living age 52, hx T2DM, HTN Maternal grandmother: deceased age 65 from breast cancer Maternal grandfather: deceased age 54 from MI