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Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular SystemDiscussion: Assessing the Heart, Lungs, and Peripheral Vascular SystemINITIAL POSTEpisodic/Focused SOAP NotePatient Information:HL 64years, White Male.Subjective DataChief Complaint:The patient presents to the clinic with the complaints of cough with sputum and shortness of breath since past five days. History of Present Illness: 64year-old HL White male is here with the complaints of cough and shortness of breath (SOB) since past five days. The patient also says he secrets thick sputum which is green in color and blood sometimes. Associated exacerbating factors is walking and talking for longer time and there are no relieving factors to help with cough and SOB. Current Medications: OTC: Tylenol 650mg, three times a day per oral. Allergies: No known allergy to medication, food, and environment.Past Medical History: There is no history of past surgery, hospitalization or any accidents. Immunization history is not provided. No history of any chronic diseases such as diabetes mellitus, hypertension, heart diseases, or stroke.
Social History: No occupation and major hobbies, family status provided. No Smoking, alcohol history provided. No history of drug abuse. Always wears seat belts and he has working smoke detectors in the house. He says living environment is safe and, does not use cell phone while driving. Family History: No history of illnesses with possible genetic predisposition, no contagious or chronic illnesses. No history provided about the family member.Review of System:GENERAL: Fever, chills, sweat, weakness or fatigue.HEAD: No headache, no history of head injuryEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat:No hearing loss, sneezing, congestion, runny nose or sore throat.