NU610 Unit 1 Case Study
A 50-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80. He has hypertension, which he takes chlorthalidone 25 mg PO daily. Takes Tylenol as needed for pain. Denies seasonal or drug allergies. He has two younger siblings with no known chronic medical conditions. Last eye and dental exam two years ago. He is married in a monogamous relationship without children. Has a high school diploma. Works full-time for local landscaping business. He does not smoke, drink alcohol, use any recreational drugs and does not exercise. He denies fever, chills, weight loss or weight gain. He denies hearing changes, headaches or dizziness. He reports some visual changes when reading close-up. He denies shortness of breath, dyspnea on exertion, swelling or chest pain. He reports increase urination and thirst. Denies abdominal pain, nausea, vomiting or changes in appetite. He reports daily BM. Denies rashes or bug bites. Uses sunscreen daily due to working outside. Denies anxiety or depression. 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. Does not appear in acute distress, responses are appropriate and appears reliable source. Alert, oriented to person, place, time and situation. Well-nourished, skin warm, dry and intact. Normocephalic. Pupils size 3 mm, equal and reactive to light. Extraocular eye movements intact to six directions. Tympanic membranes gray with adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses, thyromegaly, lymphadenopathy or JVD. Regular heart rate and rhythm, S1 and S2. No bruits auscultated. Capillary refill less than 3 seconds. Breath sounds clear bilaterally to auscultation. No use of accessory muscles or purse lip-breathing. Soft, non-tender, non-distended, normoactive bowel sound. No organomegaly or guarding. Denies numbness or tingling. He reports he has not had HIV or PSA screenings.
1. Case Study Due Sunday
Instructions
· Review the following case study.
· Construct a subjective data set for the case study in a Word file from the information provided.
· Structure the subjective data set in the format provided in your lecture materials.
· Submit the Word file containing your subjective data set into Canvas.
· To support your success on the assignment the SOAP Note Assignment Instructions are attached here for your review of how to structure a subjective data set.
Assignment Resources
NU610 Unit 1 Case StudiesDownload NU610 Unit 1 Case Studies
SOAP Note TemplateDownload SOAP Note Template
_______________________
Subjective Data Set:
Chief Complaint: Routine physical examination.
History of Present Illness: The patient reports no specific complaints at this time.
Past Medical History:
Hypertension, taking chlorthalidone 25 mg PO daily.
Denies seasonal or drug allergies.
Father died at the age of 73 of a heart attack.
Mother is alive at the age of 80.
No history of surgeries.
Medications:
Chlorthalidone 25 mg PO daily for hypertension.
Tylenol as needed for pain.
Family History:
Father died of a heart attack at age 73.
Mother is alive at the age of 80.
Two younger siblings with no known chronic medical conditions.
Social History:
Married in a monogamous relationship without children.
High school diploma.
Works full-time for local landscaping business.
Does not smoke, drink alcohol, or use any recreational drugs.
Does not exercise.
Review of Systems:
Constitutional: Denies fever or chills.
Eyes: Reports some visual changes when reading close-up.
Ears, Nose, Throat: Denies hearing changes, headaches or dizziness.
Cardiovascular: Denies shortness of breath, dyspnea on exertion, swelling or chest pain.
Respiratory: Denies shortness of breath, cough or sputum production.
Gastrointestinal: Denies abdominal pain, nausea, vomiting or changes in appetite. Reports daily bowel movements.
Genitourinary: Reports increased urination and thirst.
Musculoskeletal: Denies joint pain or swelling.
Integumentary: Denies rashes or bug bites. Uses sunscreen daily due to working outside.
Neurological: Denies numbness or tingling.
Psychiatric: Denies anxiety or depression.
Immunizations:
Reports no current immunizations.
Denies recent flu shot.
Reports no history of HIV or PSA screenings.
Allergies:
Denies seasonal or drug allergies.
Health Maintenance:
Last eye and dental exam two years ago.
