NURS 550_-_Brian_Foster_Focused_Note

NURS 550_-_Brian_Foster_Focused_NoteNecessary Components for the Subjective information: Date of encounter: Patient Name or initials: Brian Foster Informant: (Source of history/Reliability) Self Chief Complaint (CC): “I’ve been having some troubling chest pain in my chest now and then for the past month.” History of present illness (HPI): include 7 attributes of principle symptoms (OLDCART) Onset: Earlier in the month Location: Middle of the chest, does not radiate Duration: Pain lasts “several” minutes. Pain passes with rest. Has experienced CP 3x this month. Last episode of CP was last Friday per patient. Characteristics: Describes pain and “tight” and “uncomfortable.” States pain is 5/10 at worst. Currently denies pain. Denies sweating, nAausea, vomiting, SOB, or palpitations with pain. Denies crushing, gnawing, or burning pain. Has never experienced this pain before first occurrence earlier this month. Aggravating Factors: Physical activity. Reports first occurrence while doing yard work, second occurrence when he had to take the stairs to his 5th floor office at work. Pain does not worsen when eating any types of food. Relieving Factors: Rest, “lying still,” sitting to rest. Treatment: Patient has not taken any medication for his chest pain. Allergies: (Medication, food, environmental, latex): Codeine (nausea, vomiting) Medications: (dose, frequency, indication) ie. Lisinopril 10 mg daily HTN (prescription, over-the-counter, vitamins/herbal supplements) Metoprolol 100 mg PO daily (Hypertension) Atorvastatin 20 mg PO daily (Hyperlipidemia) Omega-3 Fish Oil 1200 mg PO BID (OTC supplement) Past History: childhood illnesses, medical problems, surgical history, trauma, OB/GYN, psychiatric PMHx: Hypertension – Stage II – dx 1 year ago Hyperlipidemia – dx 1 year ago Surgical Hx: No surgical hx -Has never been dx with DM, CAD, and no previous tx for CP -Has never been dx with angina -Pt does not monitor BP at home, is unsure of what his typical BP is -Last EKG was 3 months ago, last stress test was 1 year ago. Per pt “everything looked fine” -PCP: Dr. Melinda Smith. Last visit was 3 months ago. Does not have a cardiologist. Family History: : Review a family health history of parents, grandparents, siblings, and children. Include: 1) current age or age of death, 2) current health status with PMH or cause of death. -Maternal grandmother died of MI, no family hx of stroke, PE, or sudden death.