Episodic_Focused_SOAP_Note_Template (1).doc - NURS 6512 Week 7 Assessment of the Heart Lungs and Peripheral Vascular System Patient Information MH 64

Episodic_Focused_SOAP_Note_Template (1).doc - NURS 6512...

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NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System Patient Information: MH, 64, MALE, Caucasian S. CC “I can’t seem to catch my breath lately and I have no energy.” HPI : 64-year-old Caucasian male presents to the clinic with complaint of new onset of dyspnea and fatigue. He reports having orthopnea and has been sleeping in his recliner for the past couple of nights. Patient additionally reports that he has noticed a 5lb increase in his weight just this week without change in his diet. Patient explains that he has been prescribed a Lasix 20mg daily, but decided to stop taking it recently because it makes him urinate a lot. Location: N/A Onset: 3 days ago Character: N/A Associated signs and symptoms: Fluid accumulation in the lower extremities and around the abdomen Timing: Becomes worse at night when lying down flat Exacerbating/ relieving factors: Activity Severity: N/A Current Medications : Lasix 20mg po daily Coreg 12.5mg po daily
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Allergies: PCN – hives and pruritus PMHx : Appendectomy in 1992. Patient last received a tetanus shot after a minor cut on his hand last year. Patient has a diagnosis of HTN for which he takes Coreg 12.5mg daily. Soc Hx : He is a retired school teacher that remains very active. Patient describes himself as an “occasional drinker”. He reports that he has 1-2 drinks per month when he goes to college football games. He reports that he is a smoker, but he’s reduced the amount he smokes to three cigarettes per day. He denies the use of illicit drugs. Reports that he uses his seat belt about half the time when in a vehicle. He admits to using his phone to make calls while driving but he avoids reading text messages. Patient explains that he does have smoke detectors in his home that he checks every six months. Fam Hx : Father: Deceased at age 73 from heart disease Mother: Deceased at age 66 from CVA Siblings: 3 younger siblings. All siblings are living and without known medical conditions. Maternal Grandmother: Deceased age 98 from multiple CVAs Maternal Grandfather: Deceased at age 71 from MI Paternal Grandmother: Deceased at age 79 from complicated pneumonia Paternal Grandfather: Deceased at age 38 in a MVA ROS : GENERAL: Patient appears well-nourished. Alert and oriented, dress is appropriate for season. Alert, oriented, and able to provide history without difficulty. HEENT: Eyes: Denies decreased visual acuity, blurred vision, double vision, or yellow sclera. Ears, Nose, Throat: No hearing loss, congestion, sneezing, sore throat, or rhinitis. SKIN: Denies pruritus, rash, or areas of hyperpigmentation. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. 3/6 systolic murmur noted during auscultation of heart sounds. HX of HTN RESPIRATORY: Shortness of breath that is worsened by activity. Rales heard in all lung fields with auscultation.
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  • Summer '15
  • shortness of breath, productive cough

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