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Documentation for Health Assessment

Documentation for Health Assessment. Subjective. CC: 86 year old white male presents to ER with c/o chest pain and shortness of breath

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Documentation for Health Assessment

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  1. Documentation for Health Assessment

  2. Subjective • CC: 86 year old white male presents to ER with c/o chest pain and shortness of breath • HPI: crushing pain in center of chest for two hours, began suddenly with no obvious stimulus, radiates to chin; not relieved by ibuprofen; accompanied by malaise, nausea, and dyspnea

  3. +Chest pain +HTN +Palpitations +DOE -Orthopnea -Paroxysmal Nocturnal Dyspnea +Hx of MI -Rheumatic fever +Heart murmur -Valve problems Last ECG 06/2004 Other heart tests – stress, echo, etc. +Claudication +Peripheral/dependent edema -Varicose veins -Thrombophlebitis +Cool extremities +Loss of leg/toe hair +Discoloration of extremities -Ulcers Cardiovascular ROS

  4. Vital Signs • TPR: 97.5 degrees F, 105 bpm, 28 rpm • BP 146/92 • Pain 9/10

  5. Physical Exam

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