DB week 7 initial.docx - Review of case study 2 Patient Initials RH Age 50 Gender Male SUBJECTIVE DATA Chief Complain(CC Shortness of breath cough and

DB week 7 initial.docx - Review of case study 2 Patient...

This preview shows page 1 - 3 out of 5 pages.

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
Image of page 1
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.
Image of page 2
Image of page 3

You've reached the end of your free preview.

Want to read all 5 pages?

  • Summer '15
  • Pneumothorax

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture