Nurs 6512 WK6 Discuss-Adv. Assess copy 2.docx - Review of Case Study 2 Mr H 68yrs Male Subjective Data Chief Complain(CC Sharp constant chest pain and

Nurs 6512 WK6 Discuss-Adv. Assess copy 2.docx - Review of...

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Review of Case Study 2 Mr H 68yrs Male Subjective Data: Chief Complain (CC ): Sharp, constant chest pain and feels like heart racing. History of Present Illness (HPI): Mr H is a 68-year-old Caucasian male who present today with sharp, constant chest pain, increase with inspiration. Shortness of breath with or without movement. Productive cough, blood color sputum. Heart palpitation present. Redness and swelling to right calf. Recently travelled on a plane for 8hrs. Taking no meds. Pain level 8/10. Medications: none Allergies: none Past Medical History (PMH): none Past Surgical History (PSH): none Sexual/Reproductive History: Heterosexual married male Personal and Social History: married and live with wife. Denies smoking, ETOH, or illicit drugs Immunization History : unknown Significant Family History : unknown Life style : married and live with wife. Review of Systems : General: weakness. Painful movement. Diaphoretic. No recent weight loss or gain. HEENT: No changes in vision or hearing. No problem with swallowing or throat discomfort or swelling. Neck: No pain or injury reported. Respirations: c/o of shortness of breath with exertion, rest, and chest pain. Cough blood color sputum in the am.
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  • Summer '15
  • chest pain, pleuritic chest pain

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