Question

When​ asked, an alert and oriented​ 44-year-old male tells you that he called 911 because​ "my chest is​ hurting." The man is also sweating and feels as if he is going to vomit. He has a history of high blood pressure and states that this pain​ "feels just like my heart attack two years​ ago." His pulse is 88 beats per​ minute, respirations are 18 breaths per​ minute, and blood pressure is​ 156/92 mmHg. On room​ air, he has an oxygen saturation level of 95 percent. Based on this​ information, how would you document his chief complaint on the patient care​ report?

A.​"My chest is​ hurting."
B.Chest pain with an elevated BP
C.Possible heart attack
D.Myocardial infarction

Answer 1

The patient's chief complaint should be documented as "My chest is hurting." along with additional symptoms and relevant medical history.

Step-by-step explanation:

The patient's chief complaint should be documented on the patient care report as: "My chest is hurting." This statement directly reflects the patient's own words and effectively summarizes the reason for seeking medical attention. Additional relevant information, such as the patient's history of high blood pressure, previous heart attack, current symptoms of sweating and nausea, and vital signs, should also be detailed in the report to provide context to the chief complaint. Although the symptoms may suggest a possible heart attack or myocardial infarction, it is essential, as a medical professional, to refrain from diagnosing in the patient care report and instead document the symptoms and patient's statements objectively.