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NURS 6512N-24 Advanced Health AssessmentWeek 7 Discussion Post - Assessing the Heart, Lungs, and Peripheral Vascular SystemReview of Case Study #1Patient Information:Name: RHAge: 60Sex: MaleRace: CaucasianS.CC: “I am having shortness of breath, I am tired all the time and not feeling so good”HPI: Patient is 60y old white male presenting to the clinic with a history of SOB and a feeling ofuneasy for four days. He has a previous history a myocardial infarction three years ago, and 3-vessel coronary artery bypass surgery, hypertension, and CHF. The patient has beenasymptomatic since after the surgery. He noticed that about two weeks ago, he had problemcompleting his usual daily workout and has been having shortness on minimal exertion and rest.He has observed some swelling in his abdomen and legs and has taken to sleeping in a recliner ashe has had difficulty sleeping in his bed. A day before he experienced increased shortness ofbreath during conversation with his wife. He claims nothing seems to make it better but reportshe has not been taking his fluid pill because he ran out of it. He agrees he purposely did not refillit because of the frequency of urination and having to get up many times during the night. Denieschest pain, pressure or tightness. Positive for cough, expectorating clear phlegm. States he hasgained five pounds this week and rated his symptoms to be a 10/10.
Current Medications: Lasix 80 mg by mouth daily (last taken about three weeks ago)Plavix 75 mg by mouth once dailyMetoprolol 100 mg by mouth twice dailyLipitor 80 mg by mouth once daily Nitroglycerin 0.3 mg sublingual every 5 minutes as needed, up to 3 doses in 15 minutesAllergies: Reports Aspirin allergy that comes with hives and swelling of lips and tongue.PMHx: He has a medical history of MI (2015), CHF (2014), Hypertension (2013), and mumpsas a child.Past Surgical History (PSH): Patient had a surgical history of CABG 3-vessel (2015) andappendectomy in (2002).Social Hx: Pt has been married for 36 years and lives in a suburban area where crime isvirtually nonexistent. Pt worked as a fire fighter for years but took an early retirement because ofhealth issues. He has full medical coverage and receives a monthly retirement pension. Patient’swife and children has been very involved supportive in his care. He denies history of STDs/STIsbut reports occasional erectile dysfunction since after his heart surgery. No history of smoking,or illicit drug use but says he drank socially. Walks one mile daily until 2 weeks ago, prior tovisit. States he is on a heart healthy diet and is compliant. Normally can perform ADLs but hashad a hard time for past two weeks due to increased SOB. He used to enjoy playing tennis buthad to stop after his surgery.