NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
Week Six: Assessment of Heart, Lungs, and Peripheral Vascular System.
Patients presenting with reports of chest pain can be in a life-threatening condition.
Urgent and appropriate assessment to identify critical situation is crucial to immediate treatment
can be initiated. In this discussion, the assessment techniques to recognize abnormal findings in
the area of chest and lungs will be evaluated. The case of Mr. Hendricks in the second scenario
of this week’s media will be reflected in an Episodic/Focused SOAP Note format.
Episodic/Focused SOAP Note for Case # 2
Review of case study #2
Scenario: Mr. Hendricks presents with reports of consistent sharp chest pain that worsens when
taking a full breath.
Patient Information: M.H.
Age: 60 y.o.
Sex: Male
S
.
CC: “My chest hurts and it worsens when I take full breath, I feel like my heart is
racing.”
HPI: Mr. Hendricks is a 60-year-old Caucasian who presented with reports of sharp and
consistent chest pain for the past 6 hours. According to the patient, the pain level ranges from
6/10 to 9/10 which worsens when he takes deep respirations which makes him feel short of
breath. The patient stated that he felt like his heart is racing and did not feel any relief with rest
or positioning. Prior to arrival, the patient reported that he had episodes of cough with
hemoptysis 3-4 hours ago and his wife had noticed his right leg to be swollen and reddened. Mr.
Hendricks reported 5/10 pain on his right leg but unsure when the pain started as he was sitting
on the plane for eight hours last night. Denies recalling any accident or trauma that may cause his
leg to have an injury. No recent hospitalization, surgery or medication changes were reported.
Current Medications:
1.)
Fish Oil 1,000mg Capsule once daily
2.)
Atorvastatin 40mg once daily at night
3.)
Lisinopril 40mg once daily
Allergies: Penicillin-rash
Past Medical History:
1.)
Hypertension –controlled with medications (diagnosed 2014)
2.)
Hyperlipidemia – managed with medication and lifestyle modification (diagnosed
2015).
Family History
: Both parents deceased. Father died at 97 years old, he does not recall
any medical condition. Mother died at 80 years of age, diagnosed with cervical cancer.
