week 7 advanced health assessment discussion.doc - Patient Information AH 62yo WM S CC SOB and CP x3 days progressively worsening HPI AH is a 62 yo WM

week 7 advanced health assessment discussion.doc - Patient...

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Patient Information: AH, 62yo WM S. CC - SOB and CP x3 days, progressively worsening. HPI : AH is a 62 yo WM c/o of shortness of breath and chest pain that started three days ago and continues to get worse. States “I feel like my heart is racing”. Chest pain is constant and worsens when trying to take a deep breath. Nothing improves pain. Hemoptysis noted this morning. He has right calf redness and swelling with no recent injury. Recently sedentary for an eight-hour flight. Current Medications : Takes no medications. Allergies: Denies any allergies, NKDA. PMHx : No surgeries, hospitalizations, or significant past medical history. Soc Hx : Accountant for 30+ years. Married 32 years. 2 grown children and several grandchildren who live close by. Hobbies are travelling and stamp collecting. Smokes cigarettes for 25 years, a pack a day until cutting down to 3 per day in the past 6 months. Occasional alcohol use. Beer- about 1 per week. Wears seatbelt. Diet of mainly fast food and does not exercise. Fam Hx : Both parents living. Mother- DMII, Father- HTN. Brother- HTN. Sister-HTN. ROS : GENERAL: No weight loss, fever, chills, weakness. Noted fatigue for past three days. SKIN: Right lower extremity edema and redness. CARDIOVASCULAR: Chest pain and racing heart RESPIRATORY: SOB, Hemoptysis, dyspnea. GASTROINTESTINAL: No anorexia, nausea, vomiting, diarrhea or abdominal pain. NEUROLOGICAL: Alert and oriented. MUSCULOSKELETAL: Pain to right lower extremity. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No depression or anxiety. ENDOCRINOLOGIC: No sweating, cold or heat intolerance, polyuria or polydipsia. ALLERGIES: No asthma, hives, eczema or rhinitis.
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O. Physical exam : General: 62 yo WM, alert and oriented, anxious and in moderate respiratory distress. Vital Signs: T 97.9, R 32, P 112, B/P 148/88, SPO2 90% on RA. Skin: Cool, diaphoretic, no rashes, pruritis or lesions. Redness, warmth, edema to RLE. CV: Sinus tachycardia HR 112, S1, S2, no S3 S4, no murmur, 2+ dorsalis pedis pulses, chest pain. No JVD.
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