NURS 6512: Advanced Health Assessment and Diagnostic Reasoning Week 7- Initial Post Patient Information: Initials: M.H. Age: 60 Sex: MaleS. CC: “I’m not feeling so well. I feel tired all the time and feel a sharp pain when I take a breath in”. HPI: M.H. is a 60 year old caucasian male with onset of chest pain and pain on inspiration approximately 12 hours ago. He reports that the pain is sharp and consistent, and that taking a full breath exacerbates the pain and makes him feel short of breath. Reports this pain as 7/10 on a scale of 0-10. Patient also reports that he feels like his heart is racing, and nothing has been able to relieve the pain. M.H. also reports that he had an episode of coughing with hemoptysis last evening, and his wife noticed his right leg to be swollen and reddened. Patient was recently on an 8 hour flight returning from vacation, so he does not recall when his leg pain first began. Allergies: NKDA Medications: 1.Multivitamin 1 tab QD PMH: 1.HTN- was diagnosed in 2016, but lost 50 lbs and blood pressure has been well controlled without medication. FH: 1.Mother, 85- Depression, Breast Cancer 2.Father, 87- HTN 3.Children, 32, 35- no significant medical history SH : Reports smoking half a pack of cigarettes a day for 20 years, and is currently trying a smoking cessation program. Reports moderate alcohol use as 1-2 beers a week. Denies recreational drug use. States he tries to take a walk every day, and his diet is generally healthy. Married to wife of 40 years with 2 children. ROS:
General--A&Ox4. Appears anxious. Denies fevers, chills, or fatigue. Cardiovascular-- Sharp and consistent chest pain rated as 7/10. Not relieved by rest or positioning. Palpitations when taking a deep breath. Gastrointestinal--No change in appetite. Denies abdominal discomfort or change in bowel pattern. Pulmonary--Reports shortness of breath with accompanying chest pain. Episode of nonproductive cough with blood-tinged sputum. Denies congestion. No recent exposure to individuals with respiratory infection.
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- Summer '15