Review of Systems

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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:

  1. CBC: Blood tests are used to confirm an infection and to try to identify the type of organism causing the infection (Mayo Clinic, 2018.)
  2. Sputum culture: is taken after a deep cough and analyzed to help pinpoint the cause of the infection (Mayo Clinic, 2018).
  3. O2 saturation: decreased oxygen saturation indications indicates hypoxemia. Normal range should be 95-100% on RA (Mayo Clinic. 2018).