NURS 6512 N-6 Week 6 Main Discussion Post - Comprehensive...

Comprehensive SOAP Template
NURS 6512 N-6 Week 6 Review Case 1
This template is for a full history and physical. For this course include only areas that
are related to the case.
Patient Initials: RH____ Age: 60_____ Gender: _M______
SUBJECTIVE DATA:
Chief Complaint (CC): “I am having shortness of breath and not feeling so
good”
History of Present Illness (HPI): 60-year-old Caucasian male presents to the
office today experiencing shortness of breath and not feeling well for past four
days. Cardiac history is positive for a myocardial infarction three years ago,
followed by a 3-vessel coronary artery bypass surgery, hypertension, and CHF.
The patient has been asymptomatic since surgery with no c/o chest pain. Two
weeks ago, he was unable to complete his daily one mile walk at the high school
track. Over the last four days he has experienced shortness of breath walking
from room to room, and even at rest. He has noticed swelling in his abdomen
and legs. He has been sleeping in a recliner past four nights and states he is
unable to lay flat in bed. Yesterday he noticed increased shortness of breath
when talking. He claims nothing seems to make it better and that he has been on
a fluid pill in the past but ran out three weeks ago, and didn’t get it refilled
because it keeps him up all night going to the bathroom. Denies chest pain,
pressure or tightness. Positive for cough, expectorating clear phlegm. States he
has gained five pounds this week, and reports symptoms to be a 10/10.
Medications:
Lasix 80 mg by mouth daily (hasn’t taken for three weeks)
Plavix 75 mg by mouth once daily
Metoprolol 100 mg by mouth twice daily
Lipitor 80 mg by mouth once daily
Nitroglycerin 0.3 mg sublingual every 5 minutes as needed, up to 3 doses in 15
minutes
Allergies: Aspirin- hives and swelling of lips and tongue
Past Medical History (PMH):
MI in 2014
CHF in 2013
Hypertension 2012
Chicken pox as a child

Past Surgical History (PSH):
CABG 3-vessel 2014
Right inguinal hernia repair in 2000
Sexual/Reproductive History: Sexually active with wife of 40 years. Denies
history of STDs/STIs. States has occasional erectile dysfunction since heart
surgery
Personal/Social History: 30 pack/year smoking history. States he has cut down
to 3 cigarettes/day. Denies ETOH or illicit drug use. Walks one mile daily until 2
weeks ago, prior to visit. Retired from General Electric five years ago. States he
is on a heart healthy diet and is compliant. Normally is able to perform ADLs but
has a hard time for past two weeks due to increased SOB. In his spare time, he
likes to do woodworking in his garage
Immunization History:
Flu and Pneumonia vaccine 2016
Tdap vaccine in 2013
Zostavax vaccine in 2016
Significant Family History: Father died at 60- sudden death of unknown cause,
mother alive and well at 80 with osteoarthritis, sister died at 46 with AMI, has a
son who is alive with no significant health history, and a daughter age 44 with
history of hypertension
Lifestyle: Heterosexual male married 40 years living in a rural subdivision. Low
crime rate. Retired from a factory job five years ago. Receives a monthly