nr 603 wk 3 case study summary(Advanced Clinical Diagnosis and Practice Across Life Span)

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WEEK 3 CASE STUDY SUMMARY S: SUBJECTIVE DATA Chief Complaint (CC): CP/SOB 3 days ago. “My wife made me come, I feel fine.” History of present illness (HPI): Chest heaviness, SOB, “sweaty,” ... nausea, all lasting approx. 3min. None before, none since. Now only feels more tired than normal. “It could be that I have not worked out since it happened.” More energy until episode happened, now concerned because more tired than normal, especially when tries to work out. Not as much strenuous running since episode. Past Medical History (PMH): Overall health reported as good. Chicken pox as a child. H/o HTN, hyperlipidemia; both being managed with lifestyle changes. NKDA. Tonsillectomy, adenoidectomy, cholecystectomy, vasectomy, no h/o blood transfusions. Does not take flu shot. No current medications. Family History (FH): Parents: deceased (Mom: CVA complications; dad: lung cancer). Siblings: brother deceased at 44 (malignant melanoma). Another brother & sister healthy. Social History (SH): Married x20yrs, works as architect. Beer/glass of whiskey/occasional cigar when playing poker with friends. Exercises regularly up until CP 3 days ago. Review of Systems (ROS): constitutional symptoms: no reported fever, unintentional weight loss. + increased fatigue since episode 3 days ago. eyes: no reported eye drainage, itching, tearing, pain.3 WEEK 3 CASE STUDY SUMMARY ears, nose, mouth and throat: no reported ear pain/drainage, nasal drainage/congestion, mouth/throat pain. cardiovascular: chest heaviness, SOB 3 days ago, lasting 3min, none since. No reported palpitations or radiation of pain. respiratory: no reported cough, denies congestion/sputum production. SOB 3 days ago during chest heaviness, none since. gastrointestinal: denies heartburn, no reported abd pain. Slight nausea 3 days ago when chest heaviness present, none since. No v/d. genitourinary: no reported urinary symptoms. musculoskeletal: no reported musculoskeletal symptoms. integument: no reported integumentary symptoms other than sweatiness during chest heaviness episode 3 days ago, none since. neurological: no reported neurological symptoms psychiatric: no reported anxiety, depression, excessive stress endocrine: no reported unintentional weight loss/gain, hair loss, skin changes, polydipsia/polyphagia/polyuria. + fatigue as noted above. hematological/lymphatic: no reported bruising/excessive bleeding, lymphadenopathy, recent infecti [Show More]

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