Nursing Essay

634 Words Jun 16th, 2013 3 Pages
Health History

D.S is a 50 years old male, born and raised in Rochester, NY. Widower with 8 children. Work as security guard at Monroe Community College (MCC).

SOURCE OF HISTORY
Patient- very reliable historian
Medical record

CHIEF COMPLAINT
Sudden onset of chest pressure. Describe pain as “aching, heavy feeling in the chest”

PRESENT ILLNESS
Chest pain/pressure that is located primarily in the substernal area not radiating to arms that began acutely about an hour ago and lasted for 45 minutes. Started at work, pain was at it’s worst that made patient to seek help. Describes pain as aching, heavy feeling. Positive for diaphoresis, dizziness, malaise, palpitation but no nausea/vomiting, shortness of breath and symptoms are
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Patents in their 80’s, healthy, and living in independent living facility. Only one sister, living in Florida

SOCIOCULTURAL AND SPIRITUAL BELIEFS

Widower, wife died 2 years ago with cancer. Living with 8 children, oldest child is 25 years old and youngest is13 years old. Owns a house and 2 cats. Works 40-48 hrs a week as security guard. Likes to play football with children and camping. Catholic, but not practicing. High school graduated, denies any health values/belief affecting health status. States always seek medical help when needed.

REVIEW OF SYSTEMS

General – no intentional weight loss/gain, malaise, no chills/fever
Skin, hair, nails- Skin is dry, normal color. No lesions/open areas. Stretch marks on knees, back of calf and stomach, showers daily, washes hair daily and looks healthy, no scales/flaking. Nails short, good capillary refill.
Head – no headache, injury, dizziness
Eyes – no visual changes, doesn’t use glass, no drainage/infection
Ears – no hearing impairment, no tinnitus/earache, no drainage/infection, dizziness but no sensitivity to noise
Nose and Sinuses – no cold at the moment, denies environmental allergies, no smell problem
Mouth and throat – no mouth/throat sore, healthy gums, brushes and flosses daily, last dental exam 3 months ago
Neck – no lumps/goiter/pain
Respiratory – no cough/shortness of breath/dyspnea on exertion, hx of COPD and bronchitis
Cardiac - chest

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