Review of case study 2
Patient Initials:
RH
Age:
50
Gender:
Male
SUBJECTIVE DATA:
Chief Complain (CC):
Shortness of breath, cough, and feeling poorly overall.
History of Present Illness (HPI):
Mr. Hendricks is a 55-year-old Caucasian male who
presents to the office complaining of sharp, constant chest pain, increasing pain with
inspiration. He states that he experiences shortness of breath both with and without
movement. Denies relieving factors. Pain level is 8/10. Mr. Hendricks also reports a
productive cough with blood-tinged sputum. Pt admits to having heart palpitations as
well as redness and swelling in the right calf. Mr. Hedricks reports having recently being
on an eight-hour flight. Denies taking medications.
Medication:
denies
Allergies:
NKDA
Past Medical History (PMH):
none
Past Surgical History (PSH):
none
Sexual/Reproductive History:
Heterosexual married male
Personal and Social History:
married and live with wife. Denies smoking, ETOH, or
illicit drugs
Immunization History
: unknown
Significant Family History
: unknown
Life style
: married and live with wife.
REVIEW OF SYSTEMS
General:
Patient appears alert and conscious, but has weakness in RT leg due to pain and
swelling. Ne recent weight loss or gain.
HEENT:
No changes in vision/hearing; wears glasses; No problem swallowing or throat
discomfort or swelling.
Neck:
No history of pain or injuries
Respiratory: S
hortness of breath with exertion, rest, and chest pain. Productive cough
with blood colored sputum this morning.
Cardiovascular:
Constant, sharp chest pain, worsens with inspiration. Palpitations. Right
calf edema. 2+ pedal pulses, no murmur. Irregular, fast heartbeat.
Gastrointestinal:
Abdomen has normal bowel sounds. No nausea or vomiting.
You've reached the end of your free preview.
Want to read all 5 pages?
- Summer '15
- Pneumothorax
