History of Present Illness: J.H. is a 37 year old male who came to…
Question Answered step-by-step History of Present Illness: J.H. is a 37 year old male who came to… History of Present Illness: J.H. is a 37 year old male who came to your office today with complaints of “skipping heart beats and palpitations”. “My heart keeps skipping beats and every once and awhile I can feel it racing or palpitations occur”. Both the skipped beats and palpitations have been of concern to him over the past 8 months. Past Medical History No significant medical history, other than the usual seasonal cold and flu. Usual childhood illness. No history of MI, stroke, asthma, or DM.Past Surgical History NoneFamily Medical History Mother is 62 and has history of breast cancer and HTN. Father is 62 with HTN and AAA repaired. Has eight siblings who are all alive and well. He is the oldest child.Social History Smokes one pack of Marlboro daily. Social drinker on weekends. Coffee every morning at least three cups before work. Lives with wife of nine years, healthy relationship, no children at present. Works in construction and has been laid off over the past several weeks due to weather conditions.Allergies NoneMedications Occasional OTC medications for cough and cold, whatever is on sale or what his wife brings home. Daily multi-vitamins.Review of Systems Otherwise unremarkable except for complains of heart skipping palpitations.On Physical Examination BP 100/70mm Hg, HR 88, Resps 20, Temp. 98.7. On auscultation of his heart you observe that S1 and S2 are normal – there are no extra heart sounds or murmurs. You auscultate approximately 5 premature beats in a minute’s time. I’m having an issue with pertinent positives and negatives, differential diagnoses, assessment and plan for this case study Health Science Science Nursing NURSING 515 Share QuestionEmailCopy link Comments (0)
