Documentation - Chest Pain

Documentation / Electronic Health Record Document: Vitals Document: Nursing Notes Document: Nursing Notes Student Documentation Model Documentation Subjective Pt reports chest pain started about 5 mins ago Chest pain is constant Patient wasa just sitting when the chest pain began the pain is contant , reports pain of 6/10 describes pain as heavy squeezing pressure right in the middle of the chest Patient reports left shoulder hurting a tiny bit denies neck pain denies jaw pain patient denies any stress reports high blood pressure reports high cholestorol Denies regular excercise routine Patient only drinks alcohol on weekends 2/3 beers Patient reports cardiac tests and stress test are normal Diet is as follows typical breakfast is granola bar and instant shake lunch is turkey sub dinner is grilled meat and vegatables denies family histroy of stroke denies history of pulmonary embolism Grandfather died of heart attack on maternal mothers side denies sleep issues denies fever denies chills denies respiratory issues reports that he takes lipitor and lisinopril daily denies crushing pain denies tearing pain reports bowel movement this morning bowel movement was normal. denies throat issues Mr. Foster is post-op day 3 for a TURP (Transurethral resection o prostate). He is complaining of chest pain that began 5 minutes a He rates his pain at 6/10. He reports the pain is localized to the s sternal region and describes it as “squeezing pressure.” He repo the pain is constant and increasing in severity. He denies radiatio but reports some pressure in the left shoulder as well. He reports pain was accompanied by nausea at the onset, but denies emes The patient reports becoming increasingly anxious. He denies SO and palpitations. He denies tenderness, redness, or changes in surgical site. Objective Appearance no visible abnormal findings Jugular venous distention 1 cm above sternal angle chest is symmetric no visible abnormal findings inspected hands and fingernails no visible abnormal findings Inspected lower extremities and toenails no visible abnormal findings Inspected lower extremities for edema no edema present Tested capillary refill on fingers Less Than 3 seconds Tested capillary refill on toes Less Than 3 seconds Palpated carotid arteries right side no thrill 2 + expected Palpated corteroid artery left side no thrill 2 + expected Palpated PMI displaced laterally brisk and tapping Less Than 3 cm palpated right brachial pulse no thrill 2+ Palapted Left brachial pulse no thrill 2+ Palpated right radial pulse no thrill 2+ palpated left radial pulse no thrill 2+ Palpated right femoral pulse no thrill 2+ Palpated left femoral pulse no thrill 2+ Palpated right popliteal pulse no thrill 2 + Palpated left Popliteal pulse no thrill 2+ Palpated right tibial pulse no thrill 1+ palpated left tibial pulse no thrill 1+ palpated right dorsalis pedis pulse no thrill 1+ palpated left dorsalis pedis pulse no thrill 1+ measured vitals auscultated right carotoid pulse no bruit auscultated left carotoid pulse no bruit Auscultated heart sounds S1,S2,and S4 audible extra gallops auscultated abdominal aorta no bruit Auscultated right renal pulse no bruit ausucltated Iliac pulse no bruit Auscultated femoral pulse no bruit auscultated left renal pulse no bruit auscultated left Iliac pulse no bruit Auscultated left femoral pulse no bruit Auscultated breath sounds breath sounds present in all areas No adventitious breath sounds All breath sounds clear performed EKG EKG irregular , no st elevation • General Survey: Alert, but uncomfortable appearing middle-age male supine in hospital bed, and mildly diaphoretic. Elevated respiratory rate and evident distress. • Cardiovascular: No JVD, HR between 100-115, S1 & S2, + S4. murmur, no rub. Occasional PVCs appreciated. BP range 92-109 68. No carotid bruit or thrill. • Peripheral Vascular: Capillary refill <3 seconds on bilateral finge and toes, radial pulses 2+, posterior tibial and dorsalis pedis puls +1. No lower extremity edema. No varicosities, no areas of focal induration or erythema. • Respiratory: Respirations quiet and unlabored, able to speak in sentences. Lungs CTA. RR 24-26/m, O2 saturation 97-99%. • Neuro: Alert and oriented x3, follows commands, moves all extremities. • Skin: Diaphoresis. No pallor, redness, induration, or purulence noted. • EKG (interpretation): Sinus tachycardia with occasional PVCs. N ST segment elevation.