UNIT 2 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT
NU610 Unit 2 Case
Studies.
Case 1
A 50-year-old man comes to your office for a routine physical examination. He is a new patient to your
practice. He has no significant medical history and takes no medications regularly. He states his father
died at the age of 73 of a heart attack. His mother is alive at the age of 80. She has hypertension. He has
two younger siblings with no known chronic medical conditions. He does not smoke, drink alcohol, use
any recreational drugs and does not exercise. On examination his blood pressure is 126/82, pulse is 80
beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs.
CC: ROUTNIE PHYSICAL EXAMINATION
• (O)nset N/A
• (L)ocation N/A
• (D)uration N/A
• (C)haracter N/A
• (A)lleviating/Aggravating factors N/A
• (R)aditation N/A
• (T)ime N/A
Patient is a new patient presenting today
for routine physical exam.
Case 2
A 53-year-old man presents to your office for an acute visit because of coughing and shortness of
breath. He is well known to you because of multiple office visits in the past few years for similar reasons.
He has a chronic cough but reports that the past 2 days it has worsened. His sputum has changed from
white to green in color, and he has had to increase the albuterol inhaler use. He denies having a fever,
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, UNIT 2 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT
chest pain, peripheral edema. He does have a history of hypertension, peripheral vascular disease, and 2
hospitalizations for pneumonia in the past 5 years. He has a 60-pack year history of smoking and
continues to smoke 2 packs per day. On examination he is in moderate respiratory distress. His
temperature is 98.4, blood pressure 152/95, pulse 98, respirations 24, O2 is 94% on room air. His lung
exam is significant for diffuse expiratory wheezing and a prolonged expiratory phase of respiration.
There are no signs of cyanosis. The remainder of his examination I normal.
CC: COUGHING/SOB
• (O)nset 2 DAYS AGO
• (L)ocation CHEST/THROAT
• (D)uration CHRONIC- SYMPTOMS HAVE BEEN PRESENT FOR THE PAST FEW
YEARS
• (C)haracter WORSENING COUGH/ SPUTUM IS GREEN
• (A)lleviating/Aggravating factors INCREASE ALBUTEROL INHALER USE
This study source was downloaded by 100000848934517 from CourseHero.com on 07-24-2022 07:24:47 GMT -05:00
https://www.coursehero.com/file/64457937/NU610-Unit-2-Case-Studiesdocx/
NU610 Unit 2 Case
Studies.
Case 1
A 50-year-old man comes to your office for a routine physical examination. He is a new patient to your
practice. He has no significant medical history and takes no medications regularly. He states his father
died at the age of 73 of a heart attack. His mother is alive at the age of 80. She has hypertension. He has
two younger siblings with no known chronic medical conditions. He does not smoke, drink alcohol, use
any recreational drugs and does not exercise. On examination his blood pressure is 126/82, pulse is 80
beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs.
CC: ROUTNIE PHYSICAL EXAMINATION
• (O)nset N/A
• (L)ocation N/A
• (D)uration N/A
• (C)haracter N/A
• (A)lleviating/Aggravating factors N/A
• (R)aditation N/A
• (T)ime N/A
Patient is a new patient presenting today
for routine physical exam.
Case 2
A 53-year-old man presents to your office for an acute visit because of coughing and shortness of
breath. He is well known to you because of multiple office visits in the past few years for similar reasons.
He has a chronic cough but reports that the past 2 days it has worsened. His sputum has changed from
white to green in color, and he has had to increase the albuterol inhaler use. He denies having a fever,
This study source was downloaded by 100000848934517 from CourseHero.com on 07-24-2022 07:24:47 GMT -05:00
https://www.coursehero.com/file/64457937/NU610-Unit-2-Case-Studiesdocx/
, UNIT 2 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT
chest pain, peripheral edema. He does have a history of hypertension, peripheral vascular disease, and 2
hospitalizations for pneumonia in the past 5 years. He has a 60-pack year history of smoking and
continues to smoke 2 packs per day. On examination he is in moderate respiratory distress. His
temperature is 98.4, blood pressure 152/95, pulse 98, respirations 24, O2 is 94% on room air. His lung
exam is significant for diffuse expiratory wheezing and a prolonged expiratory phase of respiration.
There are no signs of cyanosis. The remainder of his examination I normal.
CC: COUGHING/SOB
• (O)nset 2 DAYS AGO
• (L)ocation CHEST/THROAT
• (D)uration CHRONIC- SYMPTOMS HAVE BEEN PRESENT FOR THE PAST FEW
YEARS
• (C)haracter WORSENING COUGH/ SPUTUM IS GREEN
• (A)lleviating/Aggravating factors INCREASE ALBUTEROL INHALER USE
This study source was downloaded by 100000848934517 from CourseHero.com on 07-24-2022 07:24:47 GMT -05:00
https://www.coursehero.com/file/64457937/NU610-Unit-2-Case-Studiesdocx/
