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NURS 6512N-26:Advanced Health AssessmentINITIAL POSTReview of Case Study #1: Heart FailurePatient 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 daysHistory 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 agoAllergies: None specifiedPast Medical History (PMH): None reported
Past Surgical History (PSH): None reportedSexual/Reproductive History: N/APersonal/Social History: + smoker, unknown for how long, states he’s trying to quit, down to 3 cigarettes per dayImmunization History: UnknownSignificant Family History:None reportedLifestyle: Nothing reportedReview of Systems: General: Extreme fatigue, weight gain of 5 lbs. over last week, denies fever or