Dailin Reyes
This 60-year-old client has been complaining about exhaustion, shortness of breath,
edema (swelling), particularly in the legs, foot, and belly, and dizziness since yesterday. The
client claims he does not take any daily prescriptions and does not have any food or drug
allergies. According to the client, these symptoms began this morning following their visit to the
gym. The customer reports that he has not been able to get any relief from the discomfort, and it
is just getting worse. The client reports experiencing sharp palpitations in his chest that feel like a
stabbing to his heart. He also reports experiencing shortness of breath and swelling in some of
his body's extremities. The customer reports that these symptoms are getting stronger and more
intense. The client reports that while he is experiencing pain in his chest, it has not extended to
other areas of his body. The customer reports that the discomfort is an 8/10, and that it has gotten
worse over time. The client reports that after doing his daily workout yesterday morning, he
began to experience pain. At first, he believed the pain might have been from the exercise, but
later on, additional symptoms started to show up. The customer also reports that the pain has
persisted since yesterday. The customer is clueless about what might be wrong with him.
Objective:
The patient's vital values are O2 95% and BP 132/84. Male, 60 years old, well fed and
tended to, physical appearance in line with age, no serious issues. Skin tone is consistently tan or
pink. Dry, warm, and well-integrated with good turgor. There are no visible parasites, and the
texture and distribution of hair are normal. There is no discoloration or clubbing of the nails.
There is a 3-second capillary refill and a pink nail bed. Two bilateral auscultations of the carotid
pulses were palpated, both without murmur. S1S2RRR with S3S4 or murmurs as the heart sound.
Risks Factors:
