Question: Assessment: : Current Vital Signs: Oxygen Heart Rhythm: Rate: Skin: IV Sites Change Date: Lung Sounds: IV Sites: Dressings: Last BM: Foley: Activity: Diet: _Drains: Fall Risk: Recommer Mendation: Current Labs: Pending Labs: Awaiting Procedures: Mode Of Arrival Private Vehicle Admission Status Voluntary Accompanied By N/A Information Provided By Client …

Assessment: : Current Vital Signs: Oxygen Heart Rhythm: rate: Skin: IV sites Change Date: Lung sounds: IV sites: Dressings: Last BM: Foley: Activity: Diet: _Drains: Fall Risk: Recommer mendation: Current Labs: Pending Labs: Awaiting Procedures: Mode of arrival Private vehicle Admission status Voluntary Accompanied by N/A Information provided by Client Present concern Client presents to the emergency department with reports of chest pain, headache and shortness of breath History of present illness New onset of chest pain History of prior psychiatric treatment Generalized anxiety disorder Previous illness/surgery NA Medications Paroxetine (Paxil) 20 mg PO daily, reports not having taken for approximately 2 weeks; Ortho Tri-Cyclen 1 tablet PO daily Diagnostics/Labs Completed in the emergency department, ECG – noncontributary Social/Cultural College student Spiritual Not able to discuss at this time HISTORY AND PHYSICAL Spiritual Not able to discuss at this time Sleep habits Reports poor, awakens frequently at night Nausea/Vomiting Denies Physical Vital signs Blood pressure: 148/76, heart rate: 115, respiratory rate: 32, temperature 37.0° C (98.6° F), oxygen saturation: 96% Neurosensory Oriented to time, person, and place Head and neck No redness, edema, visible abnormalities, report of occipital lobe headache and pain of 2/10 Cardiac and peripheral vascular Heart rate and rhythm regular, no murmurs, pulses +2 equal bilaterally, report of chest pain of 2/10 over mid to lower sternum Respiratory Respirations shallow and labored, lung sounds clear bilaterally to auscultation Gastrointestinal Abdomen soft, nontender, bowel sounds present in all 4 quadrants Musculoskeletal Gait steady, denies pain Skin Pink, warm, diaphoretic General appearance Appropriate, clean appearance MEDICATION ADMINISTRATION RECORD Order Date Stop Date 0700-1900 1900-0700 Scheduled Medications Paroxetine (Paxil ) 20 mg PO daily 02/14/XX 02/14/XX Ortho Tri-Cyclen 1 tablet PO daily