Walden University - NURSING: NURS6512 Health Assessment Week 6 discussion: Case Study: Chest pain, and SOB.. Graded A. SOAP NOTE

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SOAP NOTE Scenario # 2 Patient Initials: __Mr. H_____ Age: _60____ Gender: _M_ SUBJECTIVE DATA: Chief Complaint (CC): Chest pain, and SOB. History of Present Illness (HPI): Mr. H is a 60-y... ear-old Caucasian male who presents today with chest pain described as being “sharp”, and shortness of breath X 1 day and pain, swelling, and redness in right calf X 2 days, and states he “has had no injury to the calf”. He reports that the chest pain is constant and gets worse when he takes a deep breath, and nothing makes it better. He reports states “I just wish I could get a deep breath” Pt also reports that it “feels like my heart is racing”. Pt reports that he has a cough and coughed up blood this morning. Pt reports that he just returned from vacation and was sitting on a plane for eight hours. He rates the severity of his symptom discomfort at a 5/10 for chest pain, and 3/10 for calf pain. Medications: None Allergies: None Past Medical History (PMH): None Past Surgical History (PSH: Appendectomy – when he was 7-years-old Sexual/Reproductive History: Heterosexual Personal/Social History: He is a non-smoker; denied ETOH or illicit drug use. Immunization History: His immunizations are up to date. He received the influenza vaccine last October. Significant Family History: No siblings. He has one daughter in his 30s, healthy, living in nearby neighborhood. Lifestyle: He retired last year, has been married X 35 years, and lives in a small town. He is a college graduate, owns his own home, and car. He has a primary care nurse practitioner provider and goes for annual checkups once a year and as needed for episodic care. He has medical insurance. He has a somewhat healthy diet and eating pattern. He likes to travel with his wife. He has a good support system composed of family and friends. Review of Systems: [Show More]

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