100%(25)25 out of 25 people found this document helpful
This preview shows page 1 - 3 out of 6 pages.
NURS 6512N: Advanced Health Assessment and Diagnostic Reasoning Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular SystemAssessing the Heart, Lungs, and Peripheral Vascular SystemScenario 2: Patient Initials: HAge:60yoGender: Male Ethnicity: CaucasianSubjective Data:CC:Chest pain with shortness of breath.HPI: Mr. H is a 60-year-old Caucasian male who presents to the clinic today with right sided chest pain along with shortness of breath times two days. The pain is described as constant, “sharp”, and worsens when taking a deep breath. He rates his pain a 7/10 on severity. He states, “I just wish I could get a deep breath” and “it feels like my heart is racing”. Additional symptomsreported is a cough with bloody sputum in the AM. Prior to these symptoms starting Mr. H reports a recent trip requiring him to sit on a plane for eight hours. In addition to the chest pain and shortness of breath he reports his wife noticed that his right leg was swollen and a “little red”he does not recall any acute injury. Current Medications: NoneAllergies:NKDAPMHx: NoneSoc Hx: Current smoker. Denies ETOH abuse. Denies Illicit drug abuse. Married to his spouse.Fam Hx: NoneROS: GENERAL--AOX4. Anxious. + weakness and fatigue. Denies weight loss, fever, or chills.
HEENT--Head: Denies headache. No loss of consciousness. No head trauma. Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears: No hearing loss, tinnitus, or drainage. Nose: Denies runny nose or congestion. Throat: Denies sore throat. Speech is clear. Neck--Denies any neck tenderness. No thyromegaly. No carotid bruits. No masses or tracheal deviation noted.SKIN– No rash or itching. + redness to right lower extremity. CARDIOVASCULAR-- + right sided chest pain, + palpitations, + RLE edema. RESPIRATORY-- +shortness of breath, + dyspnea on excretion, +cough, + bloody sputum.GASTROINTESTINAL--No anorexia, nausea, vomiting or diarrhea. No abdominal pain. GENITOURINARY--No burning on urination. Denies frequency, hesitancy, dysuria, or incontinence.NEUROLOGICAL– Denies headache. No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.MUSCULOSKELETAL--No muscle, back pain, joint pain or stiffness.HEMATOLOGIC--No anemia, bleeding or bruising.LYMPHATICS--No enlarged nodes. No history of splenectomy.PSYCHIATRIC--No history of depression or anxiety.ENDOCRINOLOGIC--No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.