Shortness of breath
APA format 3 peer review article references Due 10/12/18 at 5pm
Patient Information:
Mr. H, Age 58, Male, White
S.
CC: Chest Pain “Shortness of breath with severe pain on deep inhalation” (according to Dains, Baumann, & Scheibel, (2016) before a complete HPI is taken this patient must be a quickly assessed as this complaint can have rapid, life-threatening consequences).
HPI: Reports a constant chest pain for two days ago, taking a full breath makes it worst (inhalation), pain is sharp and severe with a current PIS of 8. Subject feel like his heart is racing. Nothing makes the chest pain better. The patient also has exhibited signs and symptoms of a cough, “spit up blood,” right leg swollen and red. He recalls being stationary for an eight-hour period while on a plane, in the economy section middle row, recently from vacationing in Europe, without bathroom overall usually has a sedentary lifestyle mostly due to working 9 am -5 pm as a customer service representative at a call center. After work he sits in front of the television and watches various programs for about four hours while eating dinner, drinking a can of beer or two and smoking a cigarette before bed. It started two days ago when the patient was running to clock in at work, to avoid being late.
Location: right chest pain
Onset: 2 days ago
Character: Sharp and constant
Associated signs and symptoms: a cough, elevated heart rate, and most recently expectoration of blood.
Timing: running to avoid being late for work
Exacerbating/ relieving factors: activity makes it worst. Nothing relieves the pain.
Severity: 8/10 pain scale
Current Medications: Hydrochlorothiazide 25 mg daily for six months, and Norvasc 5 mg twice daily from one month ago for hypertension, Lipitor 80 mg daily for high cholesterol; However, has not been compliant. The patient also stated that he was taking thiamin 100 mg, folic acid 250 mcg and vitamin D 5000 daily as supplements. Currently, he only takes ginseng to boost sexual performance.