NURS 6512 WEEK 8- CASE STUDY GUIDE- RATED A+ ALREADY

History of Present Illness (HPI): A 58-year-old Caucasian male comes to the office today because he is experiencing intermittent chest pains recently and has been experiencing shortness of breath. He states that "it has been going on for a month, and I get short of breath with it too." He also says that "it is in the middle of his chest, and it becomes tight. He states it doesn't radiate. He rates his pain a 0/10 at present but has been 5/10 at times. The patient states that he has had the pain a few times this month, lasting a few minutes. He reports that it had happened when he was doing physical labor; however, the one time it was when the elevator broke down at work, and he had to use the stairs. He states when he has this pain; he sits down for a few minutes; rest seems to help. He describes the pain as "tight and uncomfortable." The pain doesn't worsen with eating generally and doesn't present after eating spicy or high-fat foods. The patient denies cough or shortness of breath at this time. He denies anxiety, states he "is pretty laid back." He has not tried any medication to relieve his discomfort. Medications: Lisinopril 20mg PO Daily, Atorvastatin 20mg PO daily at bedtime, Omega 3 Fish Oil 1200mg PO BID Ibuprofen 400mg as needed for muscle discomfort. Allergies: Drug Allergy to Codeine, has nausea or vomiting. No latex allergy and states he does have some environmental allergies. He experiences a "runny nose" at times but doesn't take medication for it. Past Medical History (PMH): The patient has a history of high cholesterol and hypertension and denies any angina or coronary artery disease. He reports he has had a recent EKG and a stress test that were normal. He denies having diabetes and has not had any hospitalizations. Past Surgical History (PSH): He has not had any surgeries Personal/Social History: The patient states that he does not smoke; however, he endorses moderate alcohol intake only on weekends. He says he has never used any illegal substances. Immunization History: Immunizations up to date. His last tetanus was 10/2014, and he has had his influenza vaccine this season This study source was downloaded by from CourseH on :34:55 GMT -05:00 3 Significant Family History: Include a history of parents, grandparents, siblings, and children. The patient's father died of colon cancer at age 75. He has hypertension and was obese. Mother is 80 years old and has type 2 diabetes and hypertension. Sister is 52 and has type 2 diabetes and hypertension. Brother died in a car accident at age 24. Maternal grandmother died of breast cancer at age 65, and paternal grandmother died of pneumonia at age 78. Paternal grandfather died of "old age" at age 85. He has a son that is 26 that is healthy, and his daughter is 19 and has asthma. Review of Systems: General: Patient states he has had a recent weight gain of 20 pounds. He states he used to ride a bicycle for exercise until it was stolen a few years ago. He says he watches his diet but does enjoy a steak sometimes. He denies fever, chills, or night sweats. Cardiovascular/Peripheral Vascular: The patient denies a history of angina, edema, or circulation problems. States he hasn't had blood clots, rheumatic fever, or a history of a heart murmur. He doesn't bleed or bruise easily. He states he doesn't note any swelling anywhere on his body. Respiratory: He denies having a recent respiratory illness. He states he has had no cough, and shortness of breath was with chest pain. Gastrointestinal: He denies any abdomen pain, states that his bowels move regularly, and denies nausea or vomiting. He denies heartburn, GERD, or bloating. Musculoskeletal: He doesn't believe that his chest pain is related to muscle issues. Psychiatric: The patient denies having anxiety or panic attacks. OBJECTIVE DATA: Physical Exam: Vital signs: Pulse rate 104, blood pressure 140/90, respirations 19, pulse oximeter 98%. Height 5'11, Weight 197 lbs. BMI 27.5 General: Mr. Foster is a well-developed, well-nourished Caucasian male who is alert and oriented. He is cooperative and answers all questions appropriately. He appears to be a good historian. Cardiovascular/Peripheral Vascular: The patient's color is pink, skin warm and dry. No JVD distension, S1, S2, and S3 audible. Gallop present. Right carotid 3+ positive for both a bruit and thrill. Left carotid 2+ without bruit or thrill. Radial, brachial and femoral arteries 2+ amplitude and no thrills noted bilaterally. PMI displaced laterally, brisk and tapping. Respiratory: No shortness of breath at this time; has fine crack