GNUR 425 Documentation Template: Adult Patient
Patient: Florence Blackman
Date of patient visit: 2/14/2022
CC: 49-year-old female presents with “intermittent squeezing chest pain”
HPI: 49-year-old female presents today with complaints of exertional mid-
chest pain that has been occurring for the past 2 weeks. The patient describes
the pain as a “squeezing feeling” that radiates to her left arm while she was
cross country skiing in extreme cold weather. The patient states that the pain
worsens in cold weather and is accompanied by dyspnea that is only
alleviated with rest. The patient reports the chest pain to be moderate and
reports a 6/10 on a pain scale when episodes occur. The patient reports a
history of hypertension and hypercholesterolemia and reports a family
history of heart disease. Upon physical examination, the patient is slightly
overweight with a BMI of 25.5 but has a normal physical examination.
Medications: Hydrochlorothiazide (HCTZ) 12.5mg daily
Allergies: (medication, environmental, food) The patient denies any
medication, environmental or food allergies
PMH: Hypertension and hypercholesterolemia. Denies other chronic
medical conditions.
LNMP/OB History (if indicated): The patient has no living children.
PSH: Denies any surgical or dental procedures.
Sexual History (if indicated): Deferred for this exam.
, Hospitalizations: None.
Health Maintenance: Reports going to primary care provider every 4
months to monitor her cholesterol and blood pressure.
Immunizations: Immunizations are up to date. Completed all childhood
vaccines.
Family History: Paternal history of stroke. Maternal history of heart
disease. Her sister had open heart surgery at age 58.
Social History:
Substances (Tobacco, alcohol, illicit drugs, caffeine):The patient
denies illicit drug use. The patient was a history smoking cigarettes (5 pack a
year) and quit 15 years ago. Reports mild caffeine intake and reports
drinking 1-2 glasses of wine a day. Denies history of alcohol abuse or
excessive alcohol consumption.
Home environment: The patient lives alone in a loft and reports a
safe home environment.
Employment type: Currently a marketing executive with her own
firm. Reports work hours and “long and demanding.”
Diet: Eats fast food and goes out to eat at restaurants regularly.
Sleep: Sleeps adequately and denies chest pain or dyspnea during
sleep.
Exercise: Active lifestyle. Performs aerobic exercises three times a
week.
Patient: Florence Blackman
Date of patient visit: 2/14/2022
CC: 49-year-old female presents with “intermittent squeezing chest pain”
HPI: 49-year-old female presents today with complaints of exertional mid-
chest pain that has been occurring for the past 2 weeks. The patient describes
the pain as a “squeezing feeling” that radiates to her left arm while she was
cross country skiing in extreme cold weather. The patient states that the pain
worsens in cold weather and is accompanied by dyspnea that is only
alleviated with rest. The patient reports the chest pain to be moderate and
reports a 6/10 on a pain scale when episodes occur. The patient reports a
history of hypertension and hypercholesterolemia and reports a family
history of heart disease. Upon physical examination, the patient is slightly
overweight with a BMI of 25.5 but has a normal physical examination.
Medications: Hydrochlorothiazide (HCTZ) 12.5mg daily
Allergies: (medication, environmental, food) The patient denies any
medication, environmental or food allergies
PMH: Hypertension and hypercholesterolemia. Denies other chronic
medical conditions.
LNMP/OB History (if indicated): The patient has no living children.
PSH: Denies any surgical or dental procedures.
Sexual History (if indicated): Deferred for this exam.
, Hospitalizations: None.
Health Maintenance: Reports going to primary care provider every 4
months to monitor her cholesterol and blood pressure.
Immunizations: Immunizations are up to date. Completed all childhood
vaccines.
Family History: Paternal history of stroke. Maternal history of heart
disease. Her sister had open heart surgery at age 58.
Social History:
Substances (Tobacco, alcohol, illicit drugs, caffeine):The patient
denies illicit drug use. The patient was a history smoking cigarettes (5 pack a
year) and quit 15 years ago. Reports mild caffeine intake and reports
drinking 1-2 glasses of wine a day. Denies history of alcohol abuse or
excessive alcohol consumption.
Home environment: The patient lives alone in a loft and reports a
safe home environment.
Employment type: Currently a marketing executive with her own
firm. Reports work hours and “long and demanding.”
Diet: Eats fast food and goes out to eat at restaurants regularly.
Sleep: Sleeps adequately and denies chest pain or dyspnea during
sleep.
Exercise: Active lifestyle. Performs aerobic exercises three times a
week.
