Chief complain1

docx

School

Jomo Kenyatta University of Agriculture and Technology *

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Course

222

Subject

Nursing

Date

Nov 24, 2024

Type

docx

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Uploaded by CaptainRoseStingray27

Patient Name: Brian Foster Chief complaint Reports chest pain History of Presenting Illness Reports chest pain started about five minutes ago Reports chest pain has been constant since it began Reports sitting in bed when pain began Reports current pain is 6/10 Asked about on characteristics of the pain Describes pain as tight and uncomfortable Denies crushing pain Denies gnawing or tearing pain Denies burning pain Reports pain location is in middle of the chest Reports slight pain in left shoulder Denies arm pain Denies back pain Denies jaw pain Denies neck pain Reports pain is aggravated by movement Reports generally low stress lifestyle Denies history of anxiety Denies history of panic attacks Past Medical History

Reports high blood pressure Reports high cholesterol Denies history of pulmonary embolism Denies history of angina Denies history of rheumatic fever Denies history of heart murmur Reports taking high blood pressure medication Reports high blood pressure medication is Lisinopril High blood pressure medication dose is 20mg High blood pressure medication is taken once daily Reports taking high cholesterol medication Reports high cholesterol medication is Atorvastatin (Lipitor) Reports high cholesterol medication dose is 20mg Reports high cholesterol medication is taken once daily Reports recent EKG test Reports annual stress test Reports belief that EKG was normal Reports belief that stress test was normal Denies illicit drug use Denies tobacco use Reports moderate alcohol consumption Reports drinking only on weekends Reports drinking 2-4 alcoholic drinks per week Reports 2-3 drinks in a single sitting Denies having a regular exercise routine

Reports most recent meal was previous night at 8 p.m. Reports meal consisted of buffalo wings Reports typical breakfast is granola bar and instant breakfast shake Reports typical lunch is turkey sub Reports typical dinner is grilled meat and vegetables Denies moderating salt intake Review of Systems Denies palpitations Denies swelling Denies circulation problems Denies blood clots Denies easy bleeding Denies easy bruising Denies fever Denies chills Denies fatigue Denies sleep issues Denies recent weight changes Denies night sweats Denies dizziness or lightheadedness Denies cough Denies shortness of breath while lying down Denies blue skin

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Denies sore throat Denies difficulty swallowing Denies diarrhea Denies constipation Denies flatus Denies bloating Denies heartburn or GERD Reports earlier nausea Denies vomiting Family History Reports family history of heart attack Denies family history of stroke Denies family history of pulmonary embolism Patient Vitals: Weight 19lbs, Height 5’11” Home medications: Lisinopril (Prinivil) 20mh PO daily Atorvastatin (Lipitor) 20mg PO daily at bedtime, last dose 10pm yesterday (hyperlipidemia) Omega 3 fish oil 1200mg PO BID, last dose 8am (OTC supplement) Allergies: Codeine, nausea and vomiting Immunization: Tdap 10/2014 Influenza vaccine this season Medical History: Hypertension- Stage II, diagnosed 1 year ago Hyperlipidemia-diagnosed 1 year ago

No surgical history Family History Father: hypertension, hyperlipidemia, obesity, died of colon cancer, age 75 Mother: type 2 diabetes, hypertension, age 80 Brother: died age 24 in motor vehicle accident Sister: type 2 diabetes, hypertension, age 52 Maternal grandmother: died f breast cancer, age 65 Maternal grandfather: died of heart attack, age 54 Paternal grandmother: died of pneumonia, age 78 Paternal grandfather: dies of “old age” at age 85 Son: healthy, age 26 Daughter: asthma, age 19 Social History No past or present tobacco use Reports drinking 2-3 alcoholic beverages (beer) per week Denies use of marijuana, cocaine, heroin or other illicit drugs

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