Discussion Week 6.docx - NURS 6512 Advanced Health Assessment and Diagnostic Reasoning INITIAL POST Case Study#3 SUBJECTIVE DATA Chief Complaint(CC

Discussion Week 6.docx - NURS 6512 Advanced Health...

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NURS 6512: Advanced Health Assessment and Diagnostic Reasoning INITIAL POST Case Study #3 SUBJECTIVE DATA: Chief Complaint (CC): Shortness of breath, cough, feeling poorly. History of Present Illness (HPI): Mr. Hendricks is a 55 year old Caucasian male who presents today with a complaint of shortness of breath, cough and feeling poorly. He is a long-time smoker who states that he was in his normal state of health until two days ago when he started experiencing shortness of breath. The patient states that he has also been coughing, bringing up thick green secretions and feels that the cough is getting worse. He states that he feels tired all of the time now. Walking makes the shortness of breath worse and even talking is difficult. He states that nothing seems to make it better. He felt that he had chills and a fever last night and took Tylenol which helped minimally. The patient said he feels poorly, had a difficult time sleeping last night and feels that he is getting worse. Medications: 1. Lisinopril 25 mg oral tab daily 2. Over-the-counter Tylenol 325 mg tabs, 2 tabs as needed. Allergies: No known allergies to drugs, food, or environment. Past Medical History (PMH): 1. Hypertension Past Surgical History (PSH): 1. Colonoscopy 2. Hemorrhoidectomy Sexual/Reproductive History: Patient is sexually active. Has had single partner for last 26 years. Personal/Social History: Smoker for 20 years, has tried quitting and is now down to 3 cigarettes a day. The patient uses alcohol occasionally and denies illicit drug use.
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