DiscussionWk7.docx - Review of Case Study#2 Episodic\/Focused Assessing the Heart Lungs and Peripheral Vascular System Patient Information Mr H 67 yr

DiscussionWk7.docx - Review of Case Study#2...

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Review of Case Study #2: Episodic/FocusedAssessing the Heart, Lungs, and Peripheral Vascular SystemPatient Information:Mr. H., 67 yr., Male, Caucasian S.CCChest pain with shortness of breath. HPI: Mr. H is a 67-year-old Caucasian male who presents today with chest pain to his right middle chest ongoing for 3 days. Patient reports the pain as “sharp” and constant and rates it a 7/10 in severity. The pain is located on the right side of the chest and is accompanied by shortness of breath with no relieve even at rest. He states, “I just wish I could get a deep breath” Pt also reports that it “feels like my heart is racing”. Pt reports that he has a cough and coughed up blood this morning. Pt reports that he just returned from vacation and was sitting on a plane for eight hours. Reports his wife noticed that his right leg was swollen and that there are some pain and redness on his right calf; does not recall acute injury. Current Medications: None Allergies: NKDA PMHx: NA Soc Hx: NA Fam Hx: NA ROS: GENERAL: + Weakness and fatigue. No weight loss, fever, chills. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or a sore throat. SKIN: Redness and swelling on RLE. No rash, itching, or bruising. CARDIOVASCULAR: + Chest pain right and middle chest, palpitations, RLE edema RESPIRATORY: + SOB, dyspnea on exertion, cough, hemoptysis. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: Denies burning on urination. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: Denies joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
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  • Summer '15
  • NURS 6512N

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