RN Nurs 550
Focused Note
Subjective:
Patient Name or initials: Brian Foster
Informant: The informant is the patient who is a reliable historian.
Chief Complaint (CC): Chest pain
History of present illness (HPI): Mr. Foster notes intermittent pain for a month, felt like
heartburn, and lasted only a couple of minutes. He notes when the pain occurs it is mostly
midsternum. The sensation is tightness of the chest. Mr. Foster notes the pain presents
during physical activity. He states, “The first time it happened He notes lying still, or rest
helps to alleviate the pain.
Allergies: Codeine. Codeine causes nausea and vomiting.
Medications: Metoprolol 100mg PO daily which he takes for his high blood pressure.
Atorvastatin 20mg PO daily at bedtime, last dose 10pm at bedtime yesterday, and
Omega-3 fish oil 1200 mg PO BID, last dose 8am, which he is on for his high
cholesterol.
Past History: Mr. Foster denies any surgical history. Past medical history include stage
II high blood pressure diagnosed one year ago, and high cholesterol also diagnosed one
year ago.
Family History: Mr. Foster’s father passed away at the age of 75 from colon cancer. His
PMH included hypertension, hyperlipidemia, colon CA, and obesity. Mr. Foster’s mother
is still living. She is 80 years of age, and her PMH include type-2 diabetes, and
hypertension. Mr. Foster’s brother passed away at the age of 24 from a motor vehicle
accident. His sister is still living, and is 52 years of age. Her PMH include type-2
, RN Nurs 550
diabetes, and hypertension. Mr. Fosters’ son is living, is 26 years old, and relatively
healthy. His daughter is 19 years of age, still living, and has asthma.
Personal and Social History:
Mr. Foster does not have a past or present history of tobacco use, however he does
acknowledge drinking 2-3 alcoholic beverages a week. Mr. Foster also denies a history of
illicit drug use.
Health Promotion/Maintenance Activities: Mr. Foster was told to cut out red meat
from his diet. He was also instructed to continue to take his medications as prescribed,
and was told to weigh himself at the same time wearing the same clothing daily. Mr.
Foster was also instructed to do some light exercises at least 3 to 4 days per week. He
was told to eat fresh fruits and vegetables. Mr. Foster was instructed to follow up with his
PCP and cardiologist.
Tobacco Use: Mr. Foster does not currently smoke and does not require health
promotion teaching regarding tobacco use.
Alcohol and Drug use: Mr. Foster has no history of recreational drug use, however he
was urged to reduce his alcohol intake to 1-2 drinks per week.
Pertinent Review of systems (ROS):
General: Mr. Foster notes gaining 15 to 20lbs over the last couple of years. The weight
gain does not appear to be out of the ordinary. No complaint of fatigue noted. No muscle
weakness or weight loss.
Neck: No neck pain, nor limited range of motion noted.
Respiratory: No shortness of breath, cough, or wheezing noted.
CV: Mr. Foster does note chest pain on exertion, however, denies syncope, tachycardia,
Focused Note
Subjective:
Patient Name or initials: Brian Foster
Informant: The informant is the patient who is a reliable historian.
Chief Complaint (CC): Chest pain
History of present illness (HPI): Mr. Foster notes intermittent pain for a month, felt like
heartburn, and lasted only a couple of minutes. He notes when the pain occurs it is mostly
midsternum. The sensation is tightness of the chest. Mr. Foster notes the pain presents
during physical activity. He states, “The first time it happened He notes lying still, or rest
helps to alleviate the pain.
Allergies: Codeine. Codeine causes nausea and vomiting.
Medications: Metoprolol 100mg PO daily which he takes for his high blood pressure.
Atorvastatin 20mg PO daily at bedtime, last dose 10pm at bedtime yesterday, and
Omega-3 fish oil 1200 mg PO BID, last dose 8am, which he is on for his high
cholesterol.
Past History: Mr. Foster denies any surgical history. Past medical history include stage
II high blood pressure diagnosed one year ago, and high cholesterol also diagnosed one
year ago.
Family History: Mr. Foster’s father passed away at the age of 75 from colon cancer. His
PMH included hypertension, hyperlipidemia, colon CA, and obesity. Mr. Foster’s mother
is still living. She is 80 years of age, and her PMH include type-2 diabetes, and
hypertension. Mr. Foster’s brother passed away at the age of 24 from a motor vehicle
accident. His sister is still living, and is 52 years of age. Her PMH include type-2
, RN Nurs 550
diabetes, and hypertension. Mr. Fosters’ son is living, is 26 years old, and relatively
healthy. His daughter is 19 years of age, still living, and has asthma.
Personal and Social History:
Mr. Foster does not have a past or present history of tobacco use, however he does
acknowledge drinking 2-3 alcoholic beverages a week. Mr. Foster also denies a history of
illicit drug use.
Health Promotion/Maintenance Activities: Mr. Foster was told to cut out red meat
from his diet. He was also instructed to continue to take his medications as prescribed,
and was told to weigh himself at the same time wearing the same clothing daily. Mr.
Foster was also instructed to do some light exercises at least 3 to 4 days per week. He
was told to eat fresh fruits and vegetables. Mr. Foster was instructed to follow up with his
PCP and cardiologist.
Tobacco Use: Mr. Foster does not currently smoke and does not require health
promotion teaching regarding tobacco use.
Alcohol and Drug use: Mr. Foster has no history of recreational drug use, however he
was urged to reduce his alcohol intake to 1-2 drinks per week.
Pertinent Review of systems (ROS):
General: Mr. Foster notes gaining 15 to 20lbs over the last couple of years. The weight
gain does not appear to be out of the ordinary. No complaint of fatigue noted. No muscle
weakness or weight loss.
Neck: No neck pain, nor limited range of motion noted.
Respiratory: No shortness of breath, cough, or wheezing noted.
CV: Mr. Foster does note chest pain on exertion, however, denies syncope, tachycardia,
