Answer Happy

Subjective Data:
Case Study: B K. is 56-year-old Caucasian female patient
recently diagnosed with non-small cell lung cancer after an
endobronchial lung biopsy last week. H. G. has a 40-year
history of smoking. She is scheduled for a left hilar lung
mass lung removal next week. Her husband brought her to the
emergency room today because has been ill the last 3 days with
nausea and vomiting. This morning he states she was confused.
Past Medical/Surgical History
Medications
Allergies
Family History
Social History
Review of Systems
Objective Data
Physical Assessment
General/Neurological
Oriented to self only
Able to follow commands
Lethargic
Head (HEENT) & Neck
PERRLA
No enlarged lymph nodes
Cardiac
Normal Sinus rhythm
No murmurs or rubs
Peripheral Vascular
Radial pulses weak and thready bilaterally
Dorsalis pulses + 1 bilaterally
Lower extremities are warm
Respiratory
Wheezing throughout lung fields
Non-productive cough
Gastrointestinal
Abdomen soft and non-tender
Hypoactive bowel sounds
Last bowel movement 2 days ago
Genitourinary
Dark yellow urine; continent
Integumentary
Pale, dry skin
Mucus membranes are dry
Musculoskeletal
ROM within normal limits