CASE STUDY Clinical Scenario Mr. Respire, a 68-year-old retired engineer, comes to the community health clinic complaini

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Case Study Clinical Scenario Mr Respire A 68 Year Old Retired Engineer Comes To The Community Health Clinic Complaini 1 (65.03 KiB) Viewed 89 times

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Case Study Clinical Scenario Mr Respire A 68 Year Old Retired Engineer Comes To The Community Health Clinic Complaini 3 (68.34 KiB) Viewed 89 times

CASE STUDY Clinical Scenario Mr. Respire, a 68-year-old retired engineer, comes to the community health clinic complaining of (c/o) shortness of breath, a cough, and lung congestion. He reports that he had a cold for the last week and it progressively worsened over the weekend. Mr. Respire states that he has a "wet” cough and says, "I am coughing up a large amount of thick yellow-green mucous several times a day." He reports, "I have been taking Robitussin 1 tablespoon every 6 hours for the cough, but it is not helping. I think that I need an antibiotic because my wife was recently diagnosed with pneumonia." Interview Select the appropriate questions to ask your patient. "Have you been running a fever?" "When did you first feel short of breath?" "On a scale of 1 to 10, how short of breath are you?" "What medications are you currently taking?" "What is your family history?" "What is your occupation?" "Do you have any other symptoms?"
Name: Focused Review of Systems GENERAL Reports general fatigue for the past 3 days. RESPIRATORY Reports productive cough with yellow-green mucous. Shortness of breath rated at a 2/10 for the past 24 hours. Denies chest pain. Reports a fever of 99.9°F orally yesterday only. Smokes 10 cigarettes per day for the past 33 years. Reports having the pneumovax vaccine at age 60. Denies recent chest x-ray or purified protein derivative (PPD) skin test. CARDIAC Denies chest pain or orthopnea. Reports sleeping on one pillow at night. Documentation: Review of Systems Fill in the circle next to reported symptoms. Cough: 0 Productive Color of mucous: 0 Clear o White Yellow b Green O Gray Hemoptysis Nonproductive Hacking O Chronic cough Dry COMMENT Paroxysmal nocturnal dyspnea Chest pain O Chest pain with coughing O Dyspnea Rates /10 Orthopnea COMMENT OSmoker pack-years Chest x-ray: Yes: Date Immunization: Influenza: Date TB screening: Yes: Date COMMENT O No Pneumovax: Age Ο Να
Name: Assessment VITALS Temperature: 99.9°F tympanic, blood pressure 120/68; radial pulse 88; regular amplitude +2; respiratory rate 20 regular. INSPECTION Conical shape, symmetrical, A-P 1.2, skin color uniform, no accessory muscle use. PALPATION Anterior and posterior: nontender, warm, dry. Decreased tactile fremitus anterior and posterior left lower lobe (LLL). Posterior and anterior left lung asymmetrical expansion PERCUSSION Posterior: resonance right upper lobe (RUL), right lower lobe (RLL), left upper lobe (LUL), dullness LLL Anterior: resonance RUL, RML, RLL, LUL; dullness LLL Lateral: resonance RUL, RML, REL, LUL; dullness LLL AUSCULTATION Anterior: clear to muscultation (CTA) RUL, right middle lobe (RML), RLL, LUL; LLL: inspiratory wheezing and coarse crackles Posterior: CTA RUL, RLL, LUL; LLL: inspiratory wheezing and coarse crackles Lateral: CTA RUL, RML, RLL LUL: LLL: inspiratory wheezing and coarse crackles Documentation: Assessment 1 Fill in your assessment findings. VITALS Blood pressure Respiratory rate: Temperature: Pulse: COMMENE INSPECTION Anterior posterior 12 Anterior posterior 1:1 O No accessory muscle retraction Accessory muscle retraction Conical shape o Barrel shape Symmetrical Asymmetrical Bradypnea o Tachypnes Biot's Kussmuat's Cheyne-stokes COMUNE Cante