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NSG 6420 Case Study: 73-Year old male with palpitations $23.49   Add to cart

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NSG 6420 Case Study: 73-Year old male with palpitations

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  • Course
  • NSG 6420
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  • NSG 6420

CC: “I’m have been having palpitations since waking this morning” HPI: A 73-year-old Caucasian male patient arrives at the office, describing a sudden onset of palpitations that woke him from sleep. The patient denies chest pain, but expresses discomfort due to the palpitations. Additionally...

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  • October 23, 2024
  • 6
  • 2024/2025
  • Case
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  • NSG 6420
  • NSG 6420
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Oldspice
SOAP NOTE
Student Name: Course: NSG6420
Name: Date: 12/07/2023 Time: 1300
Ethnicity: White Age: 73 Sex: M
SUBJECTIVE
CC: “I’m have been having palpitations since waking this morning”




HPI: A 73-year-old Caucasian male patient arrives at the office, describing a sudden onset
of palpitations that woke him from sleep. The patient denies chest pain, but expresses
discomfort due to the palpitations. Additionally, he reports mild shortness of breath,
particularly exacerbated during exertion.


Medications: (list with reason for med )

Glimipiride 5 mg daily -Diabetes
Lisinipril 40mg once a day- Hypertension
Atorvastatin 40mg once a day- Hyperlipidemia
Tamsulosin 0.4mg daily
PMH

Allergies: NKDA



Medication Intolerances: None



Chronic Illnesses/Major traumas: hypertension, hyperlipidemia, Diabetes, BPH




Hospitalizations/Surgeries- Colonoscopy, endoscopy, lumbar surgery, cataract




Family History

M: Deceased- Cardiac
MGM: Deceased-
unknown

, MGF: Deceased- unknown F: Deceased lung cancer PGM: deceased- unknown PGF
deceased- unknown



Social History

Patient is a retired military veteran. He is married with 3 living kids. Patient is a former
smoker, denies alcohol use or substance abuse.




ROS
General Cardiovascular

Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of
breath, reports palpitations


Skin Respiratory

No rash, lesions, or other skin abnormalities Reports dyspnea denies cough.




Eyes Gastrointestinal

Denies any visual changes, complains of pain Denies abdominal pain, nausea, vomiting or
behind bilateral eyes diarrhea




Ears Genitourinary/Gynecological

Denies ear pain or hearing loss Denies discharge, dysuria hematuria.

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