Advanced Theoretical Perspectives of Nursing > SOAP NOTE > Chamberlain College of Nursing - NR 603NR603 wk3 Soap (All)

Chamberlain College of Nursing - NR 603NR603 wk3 Soap

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Sean 52yr old M S: CC: chest pain 3 days ago HPI: Sean is a 52-year-old male with a history of HTN who comes into the clinic about a chest pain he had 3 days ago. He reports that his lisinopril wa... s stopped 3 months ago. He also reports elevated cholesterol level on his last visit, but id currently managing condition through diet and exercises and other lifestyle changes. Sean reports of chest pain began 3days ago. He felt short of breath, got sweaty, nauseated with symptoms lasting about 3 mins. Although he reports that he has lost weight but he says that he is more concerned now because he feels increasing tiredness when he works. OLDCART/ROS Onset: 3 days ago Location: chest Duration: lasted 3 minutes Characteristics: was short of breath, had heavy feeling in his chest, nauseous and sweaty and tired. Aggravating Factors: increased tiredness Relieving Factors: went away on its own, has not happened again Treatment: none Severity: has had to shorten his workouts since the episode due to lack of energy. Is the pain in a specific area or more generalized? Does it radiate to back, shoulder, and jaw? Does the pain spread to your neck and arms? How and when did the pain start? Did something specific seem to trigger the pain? (food, activity?). Does it start gradually and build up or start suddenly? How long did it last? Have you lost weight recently? What are your typical workouts or recreational activities? Have you recently made changes to your exercise routine? How much do you exercise? https://www.coursehero.com/file/18605641/NR603-wk3-Soap/ This study resource was shared via CourseHero [Show More]

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