100%(10)10 out of 10 people found this document helpful
This preview shows page 1 - 3 out of 5 pages.
Review of case study 2Patient Initials: RH Age: 50 Gender: MaleSUBJECTIVE 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: deniesAllergies:NKDAPast Medical History (PMH):nonePast Surgical History (PSH):noneSexual/Reproductive History:Heterosexual married malePersonal and Social History:married and live with wife. Denies smoking, ETOH, or illicit drugsImmunization History: unknownSignificant Family History: unknownLife style: married and live with wife.REVIEW OF SYSTEMS
General: Patient appears alert and conscious, but has weakness in RT leg due to pain andswelling. 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 injuriesRespiratory: Shortness 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. Rightcalf edema. 2+ pedal pulses, no murmur. Irregular, fast heartbeat.Gastrointestinal: Abdomen has normal bowel sounds. No nausea or vomiting.