Subjective Data
Document: Provider Notes
Collection Objective
Student Documentation Model Documentation
Data Collection
Subjective medications for
Education & Empathy chest pain.
Patient information Brian Foster date of birth Episodes of chest
August 17th, a 58 year old Caucasian male pain started with
CC: mr. Foster States" I have been having physical activity
some troubling chest pain in my chest now while doing yard
and then for the past month." work
HPI:
VS:
b/p (L) ARM 146/88 mmhg
(R) arm 146/90 mmhg
MAP 109mmhg
HR 109 BPM
RR- 19
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 scale. Patient describes
pain as tight and uncomfortable. Patient
denies crushing or burning pain to the
chest. Laying down seems to alleviate the
pain with a brief rest. Not taking any
Pt. reports "I have been having some troubling chest pain in my
chest now and then for the past month." Experiencing periodic chest
pain with exertion such as yard work as well as with overeating.
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.
2/
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