NR 603 week 3 SOAP Denning

Chief Complaint (CC): Chest pain three days ago

History of Present Illness (HPI): The patient reports experiencing an episode of shortness of breath accompanied by a heavy feeling in the chest three days ago. During this episode, the patient also felt sweaty and nauseous. The symptoms lasted for approximately three minutes and have not recurred since. The patient has noted an increase in fatigue since the episode and is concerned that it may be related to not working out. Prior to this event, the patient had been feeling well and had recently started a workout routine, which had been going well. However, due to the fatigue and concern over the previous symptoms, the patient has reduced the intensity of his workouts, particularly avoiding strenuous running.

Past Medical History (PMH):

• General health: Reported as good
• Hypertension (HTN): Attempted management with lifestyle changes
• Hyperlipidemia (HLD): Attempted management with lifestyle changes

Surgical History/Hospitalizations:

• Tonsillectomy and Adenoidectomy (T&A)
• Cholecystectomy (Chole)
• Vasectomy

Immunizations:

• Does not receive the influenza vaccine

Allergies:

• No known drug allergies (NKDA)

Current Medications:

• None

Family History (FH):

• Both parents are deceased.
• Father: Died of lung cancer
• Mother: Died from complications of a stroke
• Brother: Died at age 44 from malignant melanoma
• Other siblings: One sister and one brother are healthy

Social History (SH):

• Married for 20 years
• Works as an architect
• Enjoys having a beer or a glass of whiskey and occasionally smokes a cigar when playing poker with friends

Review of Systems (ROS):

• Constitutional Symptoms: Positive for fatigue and diaphoresis
• HEENT: No information provided

This information will assist in further evaluation and management of the patient’s symptoms, particularly given the cardiovascular risk factors present, including the family history of significant health issues. Further diagnostic workup may be warranted to rule out potential cardiac or other underlying causes of the symptoms.