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Patient presents with a several day history of intermittent chest pain. Has occasional cough, but no shortness of breath. He reports a history of CAD and COPD. Medications are listed. Reveals patient afebrile, vitals normal. ENT normal, neck no adenopathy. Lungs clear, heart, regular rate and rhythm. No chest wall tenderness. 2 pitting edema of lower legs, but no calf tenderness. Chest x-ray normal except for reported COPD, CBC normal, EKG demonstrates possible atrial fibrillation. ASSESSMENT: Pleuritic chest pain Continue his regular medications. May also take Tylenol if needed for pain. Should he develop shortness of breath or increased pain, instructed to go to ER. He is to follow up with his cardiologist next week for his CAD and possible afib. CPT codes
SCIENCE
HEALTH SCIENCE
NURSING

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