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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-year-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:

 

Reference

American Heart Association. (2016). Symptoms and diagnosis of pericarditis. Retrieved from http://www.heart.org/HEARTORG/Conditions/More/Symptoms-and-Diagnosis-of-Pericarditis_UCM_444932_Article.jsp#.V31cQ7grJhE

 

Criado, F. J. (2011). Aortic Dissection: A 250-Year Perspective. Texas Heart Institute Journal, 38(6), 694–700.

 

Daley, B., J. (2015). Pneumothorax. Retrieved from http://emedicine.medscape.com/article/424547-overview

 

National Heart, Lung, and Blood Institute. 2011. What are the signs and symptoms of deep vein thrombosis? Retrieved from https://www.nhlbi.nih.gov/health/health-topics/topics/dvt/signs

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[Solved] 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-year-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 “...
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