Week 6-Initial Post - NURS 6512N-26 Advanced Health Assessment INITIAL POST Review of Case Study#1 Heart Failure Patient Initials_H Age_not specified

Week 6-Initial Post - NURS 6512N-26 Advanced Health...

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NURS 6512N-26: Advanced Health Assessment INITIAL POST Review of Case Study #1: Heart Failure Patient Initials: ___H____ Age: _not specified__ Gender: __Male __ SUBJECTIVE DATA: Include what the patient tells you, but organize the information. Chief Complaint (CC): Shortness of breath for a few days History of Present Illness (HPI): Patient (pt) complains of (c/o) shortness of beath (SOB) for a few days, worsens when walking and at nighttime, states nothing makes it better. Cannot lie flat and has been attempting to sleep in a chair. Positive (+) cough with clear phlegm sputum at night. Describes weight gain of 5 pounds (lbs.) in a week, and swelling in abdomen (ABD) and bilateral (bilat) legs. Discontinued (D/C’d) “water pill” 3 weeks ago due to frequent bathroom trips. Denies chest pain (CP) Medications: Unknown “water pill”, D/C’d 3 weeks ago Allergies: None specified Past Medical History (PMH): None reported
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Past Surgical History (PSH): None reported Sexual/Reproductive History: N/A Personal/Social History: + smoker, unknown for how long, states he’s trying to quit, down to 3 cigarettes per day Immunization History: Unknown Significant Family History: None reported Lifestyle: Nothing reported Review of Systems: General: Extreme fatigue, weight gain of 5 lbs. over last week, denies fever or
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