NURS 6512 Week 7 initial post, brief soap note.docx - NURS...

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
INITIAL POST
Case Study 1- Congestive Heart Failure
S.
CC: “Shortness of Breath”
HPI: Mr. H. is a 55-year-old Caucasian male has been experiencing shortness of breath (SOB). He stated that he
continuously feel SOB even when he is sitting down in a chair. Mr. H also reports the SOB to be worse at night
in which he sleeps in a chair frequently for relief. However, there are no interventions that have made his SOB
better. The patient reports swelling in his legs and abdomen as well as gaining five pounds over the past week.
The patient stopped taking his “fluid pill” three weeks ago because it caused him to urinate frequently.
Medications: Lasix 40mg tablet daily (Pt stated “he stopped taking medication 3 weeks ago due to excessive
urination).
Lisinopril 10mg tablet daily
Allergies: No know allergies
PMH: Positive history of congestive heart failure (CHF) and renal insufficiency (dates of diagnosis unknown by
patient). Diagnosed with hypertension and chronic obstructive pulmonary disease (COPD) in 2012.
Immunizations up to date; tetanus shot 2 years ago.
FH: Mother died 3 years ago of breast cancer; chemotherapy and radiation treatment completed but ineffective.
Father diagnosed with COPD at the age of 65, congested heart failure, myocardial infarction, and hypertension
(dates unknown by patient).
SH: Positive for current tobacco use for 35 years; smokes 1 pack of cigarettes every 2 days. Negative for illicit
drug use or alcohol consumption. Occupation of a customer service representative; married for 30 years with 2
adult children. Use of seat belt while driving; negative for cell phone use while driving.