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Assessing the Heart, Lungs, and Peripheral Vascular SystemCathy CooperWalden UniversityNURS 6512: Advanced Health Assessment and Diagnosis ReasoningInstructor: Dr. Tina HollowayOctober 5, 2016Case Study #1 Chest PainPatient Initials: _MH_ Age: _59_ Gender: __Male__SUBJECTIVE DATA: Chief Complaint (CC):Shortness of breath and fatigueHistory of Present Illness (HPI):Mr. Hendricks is a 59-year-old, Caucasian male presents with shortness of breath (SOB) and fatigue for 3x days, that is getting worse. He identifies his shortness of breath gets worse upon activity and lying down. He has been sleeping in a recliner. He states nothing helps relieve his SOB. Mr. Hendricks reports related symptoms including a cough, with clear phlegm expectorated, which wakes him up at night, swelling of his abdomen and legs, and a five-pound weight gain this week. He denies chest pain, chest tightness, or discomfort at this time. He admits to a history of smoking and reports smoking 3 cigarettes a day. Mr. Hendricks has been prescribed fluid pills in the past but “ran out” of them three weeks ago. He reports that they make him go to the bathroom all the time and wanted to stop the medication to see how he did. Medications:
1.Losartan 100 mg by mouth daily2.Lasix 40 mg by mouth daily3.Nexium 40mg by mouth daily4.Simvastatin 20mg by mouth daily Allergies:No known drug allergies Past Medical History (PMH):1.Hypertension- uncontrolled due to stopping Lasix2.Hyperlipidemia- well controlled on simvastatin and dietary changes3.Gastroesophageal reflux (GERD) – well controlled on Nexium4.Chronic Obstructive Pulmonary Disease (COPD)- not on medication at this time- smokes5.Congestive Heart Failure- uncontrolled- fluid overload-stopped LasixPast Surgical History (PSH): No previous surgeries notedSexual/Reproductive History:Heterosexual, 2 grown childrenPersonal/Social History:Smoker- 1 pack per day for + 30 years. Has recently reduced smoking to 3 cigarettes per day; denies alcohol or illegal drug use.Immunization History:Up-to-date on all immunizations. Last Flu vaccine was October 2015 and received Pneumococcal vaccine 4 years ago (2012). Significant Family History:Parents are deceases. Father had a history of smoking, CHF, and DM. Mother died of breast cancer in 2002. Both children are healthy.
Lifestyle: He is a manager at a supermarket and looking forward to retiring in the next few years. He lives in a subdivision close to work, and enjoys fishing and reading. He denies any feelings of unsafety at home or work, and denies any added stress in his life at this time.