*NURSING > QUESTIONS & ANSWERS > Focused Exam- Chest Pain | DOCUMENTATION (All)

Focused Exam- Chest Pain | DOCUMENTATION

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PatientinformationBrianFosterdateofbirthAugust17th,a58yearoldCaucasianmaleCC:mr.FosterStates"Ihavebeenhavingsometroublingchestpaininmy chestnowandthenforthepastmonth."HPI:VS:b/p(L)ARM146/88mmhg(R)arm1 ... 46/90mmhgMAP109mmhgHR109BPMRR-19O2Sat98%RATemp:36.7C(98F)Onsetofchestpainonemonthago,lasting"fewmin"ptstates,"thoughtitmay beheartburn"reports Tightanduncomfortablerightinthemiddleofthechest.Denies any painradiatingdenies anyarmpainshoulderpainbackpainorneckpain.Painonly lastafewminutes.Anuncomfortablefeelingthatlasts afewminutes reporting3episodes inthepastmonthandallfeels thesame.Paincurrently azerowhenhavingchestpainis 5outof10onpainscale.Patientdescribes painas tightanduncomfortable.Patientdenies crushingorburningpaintothechest.Layingdownseems toalleviatethepainwithabriefrest.Nottakinganymedications forchestpain.Episodes ofchestpainstartedwithphysicalactivity whiledoingyardworkPt.reports "Ihavebeenhavingsometroublingchestpaininmy chestnowandthenforthepastmonth."Experiencingperiodicchestpainwithexertionsuchas yardworkas wellas withovereating.Points tomidsternumas location.Describes painas “tightanduncomfortable.”Denies radiation.Painlasts for“afew”minutes andgoes awaywhenherests.Mostrecentepisodewasthreedays agoaftereatingalargerestaurantdinner.States “Ithas nevergotten‘really bad’”sodidn’tthinkitwas anemergency,butis concernedafterthreeepisodes inonemonthandwants his heartcheckedout.Reports mildcrampinginlegs withactivity.Denies shortness ofbreath,indigestion,heartburn.Denies chestpainatthis time [Show More]

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