Chamberlain College of Nursing - NR 509Focused Exam- Chest Pain | DOCUMENTATION. Advanced Health Assessment - Chamberlain, NR509-April-2018 Documentation / Electronic Health Record.

Document Content and Description Below

5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health 1/4 Focused Exam: Chest Pain Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment You... r Results Lab Pass Documentation / Electronic Health Record Document: Vitals Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Patient information Brian Foster date of birth August 17th, a 58 year old Caucasian male CC: mr. Foster States" I have been having some troubling chest pain in my chest now and then for O2 Sat 98% RA Temp: 36.7 C (98 F) Onset of chest pain one month ago, lasting " few min" pt states, "thought it may be heart burn" reports Tight and uncomfortable right in the middle of the chest. Denies any pain radiating denies any arm pain shoulder pain back pain or neck pain. Pain only last a few minutes. An uncomfortable feeling that lasts a few minutes reporting 3 episodes in the past month and all feels the same. Pain currently a zero when having chest pain is 5 out of 10 on pain ting. Points to midsternum as location. Describes pain as “tight and uncomfortable.” Denies radiation. Pain lasts for “a few” minutes and goes away when he rests. Most recent episode was three days ago after eating a large restaurant dinner. States “It has never gotten „really bad‟” so didn‟t think it was an emergency, but is concerned after three episodes in one month and wants his heart checked out. Reports mild cramping in legs with activity. Denies shortness of breath, indigestion, heartburn. Denies chest pain at this time. Overview dent Documentation Model Documentation in the second episode was taking stairs at work denies any pain with food. Patient confirms all medications are still current and unchanged. No new allergies noted. Confirms hypertension diagnosis and hyperlipidemia diagnosis denies any angina coronary artery disease or previous chest pain treatments. Patient does not check blood pressure on a regular basis only windows to the doctor states doctor does not seem concerned about his blood pressure Current medications: metoprolol 100 mg one po q hypertension stage 2 diagnosed 1 year ago, hyperlipidemia diagnosed 1 year ago. Denies any surgeries. Influenza uptodate, TDAP 10/2014 Soc Hx: denies any illicit drug use or tobacco use. Patient does report drinks 2 to 3. No unusual stress noted. alcoholic beverages per week (beer) no regular exercise last regular exercise he was 2 years ago. Diet consist of granola bars turkey subs and grilled meat and veggies. Unsure of salt intake. Reports drinking a one liter of water a day. drinks c: denies any fatigue increased sweating nal: Round, soft, non-tender with normoactive bowel sounds in 4 quadrants; no abdominal bruits. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. • Neuro: Alert and oriented x 3, follows commands, moves all extremities. • Skin: Warm, dry, pink, and intact. No tenting. • EKG (interpretation): Regular sinus rhythm. No ST changes.4/4 5. Prescribed aspirin regiment 6. Educate patients on signs of worsening symptoms such as MI, CVA or unstable angina 7. Educate on the importance of a healthy diet and exercise to help control hyperlipidemia 8. Educate on salt intake reduction due to ek immediate medical attention if signs or symptoms worsen and follow up Education • Educate patient regarding exercise, diet, and lifestyle modifications Referral/Consultation • Expedited referral to cardiology for evaluation and treatment, an echocardiogram, exercise stress test, and bilateral carotid doppler examination • Mr. Foster may need an additional consult with a vascular surgeon for carotid evaluation Follow-up Planning • Educate Mron and follow up If your instructor provides individual feedback on this assignment, it will appear here. [Show More]

Last updated: 1 year ago

Preview 1 out of 4 pages