NR603 wk3 Soap - Sean 52yr old M S CC chest pain 3 days ago HPI Sean is a 52-year-old male with a history of HTN who comes into the clinic about a chest

NR603 wk3 Soap - Sean 52yr old M S CC chest pain 3 days ago...

This preview shows page 1 - 4 out of 9 pages.

Sean 52yr old M S: CC: chest pain 3 days ago HPI: Sean is a 52-year-old male with a history of HTN who comes into the clinic about a chest pain he had 3 days ago. He reports that his lisinopril was stopped 3 months ago. He also reports elevated cholesterol level on his last visit, but id currently managing condition through diet and exercises and other lifestyle changes. Sean reports of chest pain began 3days ago. He felt short of breath, got sweaty, nauseated with symptoms lasting about 3 mins. Although he reports that he has lost weight but he says that he is more concerned now because he feels increasing tiredness when he works. OLDCART/ROS Onset: 3 days ago Location: chest Duration: lasted 3 minutes Characteristics: was short of breath, had heavy feeling in his chest, nauseous and sweaty and tired. Aggravating Factors: increased tiredness Relieving Factors: went away on its own, has not happened again Treatment: none Severity: has had to shorten his workouts since the episode due to lack of energy. Is the pain in a specific area or more generalized? Does it radiate to back, shoulder, and jaw? Does the pain spread to your neck and arms? How and when did the pain start? Did something specific seem to trigger the pain? (food, activity?). Does it start gradually and build up or start suddenly? How long did it last? Have you lost weight recently? What are your typical workouts or recreational activities? Have you recently made changes to your exercise routine? How much do you exercise?
Image of page 1
Did the symptoms occur after your work- out or in certain environments? Have you been diagnosed with elevated cholesterol or coronary heat disease? Do you have a family history of heart disease, heart attack, HTN, hyperlipidemia, sudden cardiac death? Any previous diagnosis of heart burn, GERD in the past? What order medications do you take? What is your diet like? Do you smoke? How many pack/day? How much do you drink? What dietary supplements or herbal medications do you take? Current Medications: none. Lisinopril stopped 3 months ago. Allergies: NKDA Immunizations: does not receive the flu shot PMH: Chickenpox as a child, hypertension, elevated cholesterol, (lifestyle management was initiated.) Surgical History: T and A, cholecystectomy, vasectomy Social History: Married for 20 years, works as a mortgage broker at a local bank. Enjoys a beer or a glass of Jameson and the occasional cigar when playing poker with his buddies Family History: Father (deceased)- HX of lung CA Mother (deceased)- died from complications of a stroke Brother (deceased)- died at age 44 from malignant melanoma. Other brothers and sisters are healthy.
Image of page 2
ROS: CONSTITUTIONAL: -fever. - chills. (+) sweaty. HEENT: - Dizziness, (-) headaches, - changes in vision, - ear pain, (-) nasal drainage, - sore throat. CARDIOVASCULAR: (+) chest pain, (+) palpations, - edema lower extremities.
Image of page 3
Image of page 4

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture