Respiratory
APA format 3 peer review references
Patient Initials: __JH_____ Age: __60_____ Gender: ____M___
Subjective Data:
Chief Complaint: Case #3 “I have a cough that’s getting worse.” (Laureate Education, 2012).
HPI: Mr. Hendricks is a 60 year-year old Caucasian male who presents today complaining of a cough that is progressively getting worse; more frequent over the past three days. He states that his cough is accompanied by expectoration of thick green secretions accompanied by some blood at times. He has associated symptoms of shortness of breath that is aggravated when walking and nothing seems to help. Patient also states that he had difficulty trying to fall asleep last night because he felt like he was getting a fever and had intermittent chills and sweats and took Tylenol. He states “I have never felt like this before and would like to know what’s going.”
Medications: over the counter Tylenol 650mg po at nights.
Allergies: No known drug or food allergies. No seasonal allergies.
Past Medical History: No medical history provided.
Past Surgical History: No surgical history provided.
Immunization history: Up to date with immunizations. Influenza shot received September 2018. Pneumococcal vaccine received October 2018.
Personal/Social History: Patient denies smoking, drinks wine socially, exercise with brisk walking three times weekly and tries to eat a balanced diet. He has a master’s degree in finance and works as an accountant at an accounting firm. He is a safe driver who drives to work daily and always wears seatbelt. He lives with his wife who is a homemaker who helps baby sit twin granddaughters. Patient denies history of recent travel to foreign country within the three months.
Review of Systems
General: productive cough with green phlegm and blood at times; shortness of breath, chills, night sweats, fever and restlessness.
HEENT: Patient denies head or nasal congestion, headache, nasal discharge, dizziness, vertigo. Patient states productive cough with green-colored sometimes bloody phlegm.
Cardiovascular: Patient denies palpations. Has some chest tightness.
Respiratory: Patient states that he has SOB that worsens with walking. Has productive cough with green-colored sputum and occasional hemoptysis. Patient states that he hears whistling noises when he breathes.
Objective Data:
Physical exam:
General: Mr. Hendricks is a 60 year old Caucasian male and a good historian who is relatively healthy and has good hygiene. Alert and oriented x 3, looks age appropriate with normal facial expression and appropriate behavior. He coughed a few times during exam and appears to be in some respiratory distress with shortness of breath.
Vital signs: Ht. 5’9”, Wt. 210 lbs; BMI= 30, blood pressure 128/70, pulse of 82, respirations of 20 and labored, temperature of 100.9 and O2 saturation on room air of 89%.
HEENT: No headache or head masses. No lesions. Wears glasses. Pupils equal and reactive to light; ears symmetrical, no tenderness or discharge. No frontal or maxillary sinus tenderness. No discharge from nose and mucosa pink and moist. Wears partial upper dentures. Throat appears red. Good hygiene.
Neck: No masses, full range of motion. Thyroid size normal.
Integumentary: Warm and most
Respiratory: Thorax symmetrical with diminished breath sounds. B/L rales and expiratory wheezes throughout. Wet productive cough.
Cardiovascular: regular heart rate with good S1 and S2 heart sounds. No S3, S4 or murmur.
Gastrointestinal: abdomen protuberant. Normoactive bowel sounds in all four quadrants.
Peripheral vascular: No peripheral edema. 2+ dorsalis pedis pulses palpated bilaterally.
ASSESSMENT:
Lab Tests and Results:
- CBC: Blood tests are used to confirm an infection and to try to identify the type of organism causing the infection (Mayo Clinic, 2018.)
- Sputum culture: is taken after a deep cough and analyzed to help pinpoint the cause of the infection (Mayo Clinic, 2018).
- O2 saturation: decreased oxygen saturation indications indicates hypoxemia. Normal range should be 95-100% on RA (Mayo Clinic. 2018).
Diagnostics:
- Chest X-ray: helps your doctor diagnose pneumonia and determine the extent and location of the infection (Mayo Clinic, 2018).