BP 165/80, HR 85, R 18, SpO2- 99%, T 36.7

Question Answered step-by-step BP 165/80, HR 85, R 18, SpO2- 99%, T 36.7Skin is warm, dry, and well perfused. Cap refill < 2seconds. Undertones matching ethnicity and background.No pain on palpation, no evidence of lumps, masses, pulsations, heaves, or lifts.2 hour history of central chest pain. Onset with exercise, eases with rest. Sharp, intermittent, radiating across to left shoulder. Currently 6/10, 2/10 at rest. Patient sitting up in bed. Awake and Alert x 3. Rubbing chest at times.Carotid: R 2+ L 2+No JVD noted supine or with HOB elevation.No scars, lesion, moles to chest- anterior or posterior. No family hx of cardiac disease. Presently on metoprolol for HTN, "forgets to take it". Smoker- 10 cigs/day x 10 years, Scottish Background.Apical pulse (PMI)- 5th ICS, MCL 2cm, 2+. Rate: 85bpm, matching radius at 85pm.S1, S2. No S3, 4 or murmurs noted.    Make a SOAP note from the following information. Name 1 NANDA diagnosis- Health Science Science Nursing Share QuestionEmailCopy link Comments (0)