NURS 6512: Advanced Health Assessment and Diagnostic ReasoningWeek 7: Initial PostAssessing the Heart, Lungs, and Peripheral Vascular SystemCase Study #3SUBJECTIVE DATA: Chief Complaint:The patient came to the clinic with the complaints of a cough with greenish secretion and shortness of breath for the past few days. History of Present Ailment:The patient is a sixty-four years-old Caucasian male presents to the clinic with the complaints of a cough and shortness of breath for the past few days. The patient likewise stated that he coughs up thick greenish sputum and blood occasionally. The shortness of breath exacerbates when walking and even when talking while sitting and nothing helps to relieve both a cough and shortness of breath. Mentioned taken Tylenol when he felt having fever, sweat, and chills.Current Medications: Over the Counter Medication:Tylenol 650mg, three times daily orally. Allergies:No known allergy to the medicine, food, and environmental.Past Medical History:Patient has no history of surgical procedure, hospitalization or accidents. The patient did not provide and vaccination history. He has no history of any chronic diseases, for example, heart diseases, stroke, diabetes mellitus, arthritis, and hypertension. Social History:Patient provided no information about occupation, hobbies, and family status. He also provided no history of smoking, alcohol, and no illicit drug use. He
continuously wears seat belts while driving and does not use a cell phone as well. He stated that living condition is safe and has a working smoke detector in his home.Family History:Patient has no family history of diseases with possible genetic predisposition, no history of chronic diseases, and history about the family member was not provided.Review of System:GENERAL:Fever, sweat, chills, and weakness.
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- Fall '17
- productive cough