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NRSE 4520 SH Brian Foster Chest Pain Document Nursing Notes
Typology: Exams
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Model Documentation Mr. Foster is post-op day 3 for a TURP (Transurethral resection of the prostate). He is complaining of chest pain that began 5 minutes ago. He rates his pain at 6/10. He reports the pain is localized to the sub-sternal region and describes it as “squeezing pressure.” He reports the pain is constant and increasing in severity. He denies radiation but reports some pressure in the left shoulder as well. He reports the pain was accompanied by nausea at the onset, but denies emesis. The patient reports becoming increasingly anxious. He denies SOB and palpitations. He denies tenderness, redness, or changes in surgical site.
Experts selected these topics as essential components of a strong, thorough interview with this patient.
A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.
Established chief complaint
Reports chest pain
Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source.
Do you have chest pain?
Pro Tip: For many patients, it is difficult to clearly describe pain. Asking Brian to rate his pain on a scale from 0 to 10 develops a consistent measure of pain severity.
On a scale of 0 to 10 how would you rate the chest pain?
Asked about on characteristics of the pain
Describes pain as tight and uncomfortable
Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
Can you describe your pain?
Denies crushing pain
Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
Is the pain crushing?
Denies gnawing or tearing pain
Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
Is the pain gnawing?
Denies burning pain
Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
Is the pain burning?
Asked about location of the pain
Reports pain location is in middle of the chest
Pro Tip: Identifying the location of a patient's pain is essential in determining which body systems are affected, the underlying cause of the pain, and how best to treat it.
Where is the pain?
Reports slight pain in left shoulder
Pro Tip: Pain radiation is an important symptom that can be helpful in understanding the cause of pain and narrowing the diagnosis.
Does the pain radiate?
Denies arm pain
Pro Tip: When combined with chest pain, arm pain can be a telling sign that the complaint may be cardiac in nature.
Do you have arm pain?
Asked about stress and anxiety
Reports generally low stress lifestyle
Pro Tip: Stress can have a profound effect on the patient's health and wellness. Asking about stress is an important part of any health assessment.
What is your usual stress level?
Denies history of anxiety
Pro Tip: Symptoms such as chest pain can be caused or exacerbated by episodes of anxiety. Asking Brian if he's ever suffered from anxiety can point to underlying stressors or triggers.
Do you have a history of anxiety?
Denies history of panic attacks
Pro Tip: Symptoms such as chest pain can be caused or exacerbated by episodes of anxiety. Asking Brian if he's ever had a panic attack can point to underlying stressors or triggers.
Have you ever had a panic attack?
Asked relevant health history
Reports high blood pressure
Pro Tip: Hypertension is the most important risk factor for stroke. Soliciting a health history from Brian will allow you to assess his risk of cardiovascular disease.
Do you have high blood pressure?
Reports high cholesterol
Pro Tip: High cholesterol can lead to cardiovascular disease. Asking Brian whether he's had a history of high cholesterol reveals important details about his cardiovascular health.
Do you have high cholesterol?
Denies history of pulmonary embolism
Pro Tip: Pulmonary embolism is one of many cardiac risk factors to ask about that can help you form a more complete picture of Brian's cardiovascular health.
Have you ever had a pulmonary embolism?
Denies history of angina
Pro Tip: A history of angina can weaken the heart and lead to further cardiovascular complications. Asking Brian about angina helps you understand his overall cardiovascular health.
Do you have a history of angina?
What medication do you take for high blood pressure?
High blood pressure medication dose is 20mg
Pro Tip: The current dose of any patient's high blood pressure medication is important to learn about because it provides useful information about the patient's treatment plan as well as potential medication interactions.
What dose of medication do you take for high blood pressure?
High blood pressure medication is taken once daily
Pro Tip: The frequency with which a patient takes his high blood pressure medications is an essential element of the complete picture of his medication treatment plan.
How frequently do you take medication for high blood pressure?
Followed up on high cholesterol treatment
Reports taking high cholesterol medication
Pro Tip: The medication that a patient takes for their high cholesterol will indicate how well controlled their condition is and how well they comply with treatment regimens.
Do you take medication for cholesterol?
Reports high cholesterol medication is Atorvastatin (Lipitor)
Pro Tip: Discovering what specific high cholesterol medication a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions.
What medication do you take for cholesterol?
Reports high cholesterol medication dose is 20mg
Pro Tip: The current dose of any patient's high cholesterol medication is important to learn about because it provides useful information about the patient's treatment plan as well as potential medication interactions.
What dose of medication do you take for cholesterol?
Reports high cholesterol medication is taken once daily
Pro Tip: The frequency with which a patient takes his high cholesterol medications is an essential element of the complete picture of his medication treatment plan.
How frequently do you take medication for cholesterol?
Asked history of cardiac tests
Reports recent EKG test
Pro Tip: An EKG test checks for electrical problems with the heart. Asking Brian whether he's had an EKG will reveal his recent medical history, cardiac health, and medical literacy.
Have you recently had an EKG test?
Pro Tip: Many drugs affect the central nervous system or can cause cardiovascular complications. Asking Brian if he uses illicit drugs will indicate whether drug use puts him at risk for health complications.
Do you use illicit drugs?
Denies tobacco use
Pro Tip: Tobacco affects the heart by reducing the amount of oxygen the blood is able to carry. Asking Brian if he uses tobacco will allow you to assess whether the condition is caused, in part, by tobacco use.
Do you use tobacco?
Reports moderate alcohol consumption
Pro Tip: Chronic alcohol use can result in cardiomyopathy. Asking Brian whether he drinks alcohol will allow you to assess whether he has any indicators of alcoholism.
How much alcohol do you consume?
Followed up on alcohol consumption
Reports drinking only on weekends
Pro Tip: Asking the patient to describe his drinking habits can identify indicators of alcoholism. It may also be helpful to ask about the context and reasons for the patient's alcohol intake. Heavy drinkers will often underestimate their drinking habits.
How frequently do you drink alcohol?
Reports drinking 2-4 alcoholic drinks per week
Pro Tip: Consumption of alcohol can impact a patient's health and is considered a risk factor for many medical conditions. Asking Brian about his drinking habits will help you determine his risk for disease linked to alcohol consumption.
How many alcoholic drinks do you have in a week?
Reports 2-3 drinks in a single sitting
Pro Tip: Asking the patient to quantify his drinking is helpful because it elicits objective data on a subject that patients may otherwise downplay.
How many alcoholic drinks do you consume at a time?
Asked about exercise
Denies having a regular exercise routine
Pro Tip: Activity levels have an important impact on cardiovascular health. Asking Brian about his exercise patterns can help you understand how his lifestyle might affect his health.
What kind of exercise do you get?
Asked about most recent meal
Reports most recent meal was previous night at 8 p.m.
What is a typical lunch for you?
Reports typical dinner is grilled meat and vegetables
Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his typical dinner will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications.
What is a typical dinner for you?
Denies moderating salt intake
Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Salt intake in particular can have a detrimental effect on blood pressure, which is why it is important to ask a patient like Brian, who suffers from hypertension, about his salt consumption.
Do you moderate your salt intake?
Asked about review of cardiovascular system
Denies palpitations
Pro Tip: Discovering palpitations can be an important clue into the patient's cardiovascular history and current condition.
Do you have palpitations?
Denies swelling
Pro Tip: Swelling can be a major indicator of cardiovascular and peripheral vascular health. Asking the patient about swelling is an important part of a thorough cardio exam.
Do you have any swelling?
Denies circulation problems
Pro Tip: Circulation is an important indicator of peripheral vascular and cardiovascular health. Asking Brian about his circulation can help diagnose vascular conditions.
Do you have any problems with circulation?
Denies blood clots
Pro Tip: Blood clots can be a sign of serious cardiovascular or related illnesses. Asking Brian about blood clots can provide valuable information about the state of his health.
Have you ever had a blood clot?
Denies easy bleeding
Pro Tip: Bleeding can be a sign of serious cardiovascular or related illnesses. Asking Brian about bleeding can provide valuable information about the state of his cardiovascular health.
Have you noticed any unusual bleeding?
Denies easy bruising
Denies sleep issues
Pro Tip: Sleep issues can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.
Have you had problems sleeping?
Denies recent weight changes
Pro Tip: Weight changes can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.
Has your weight changed?
Denies night sweats
Pro Tip: Night sweats can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.
Do you have night sweats?
Denies dizziness or lightheadedness
Pro Tip: Patients exhibiting dizziness may be at risk for several conditions as well as a fall risk. It is important to ask about dizziness to keep your patient safe.
Do you have dizziness?
Asked about review of respiratory system
Denies cough
Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. A cough in a patient complaining of chest pain is a symptom worth investigating.
Do you have a cough?
Denies shortness of breath while lying down
Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. Orthopnea in a patient complaining of chest pain is a symptom worth investigating.
Do you have difficulty breathing when lying down?
Denies blue skin
Pro Tip: Cyanosis can be a symptom of troubling cardiovascular illness, though patients may not be aware of its connection to respiratory health. Asking Brian if he has noticed any cyanosis is important in ruling out certain cardiac risk factors.
Has your skin ever turned blue?
Asked about throat problems
Denies sore throat