Questions: 1. WhataretheabnormalfindinginMsMavis? 2. Discuss yours analyze for each one? 3. What are the normal finding
Posted: Tue May 17, 2022 10:10 pm
Questions:
1. WhataretheabnormalfindinginMsMavis?
2. Discuss yours analyze for each one?
3. What are the normal finding for each one?
The Case for health assessment:
Chief Complaint: Mavis is a 55-year-old female was seen by her GP due to a chest infection, she was given a course of antibiotic and she was advised to return to the surgery for a follow up. Although she completed her prescribed treatment, she was still complaining of shortness of breath and chest tightness.
History of Present Illness: Mavis has been having symptoms of shortness of breath and chest tightening for over five years with little or no variations in her symptoms, but she tends to feel worse in the morning and in cold, damp or windy conditions. However, the timing of her breathlessness symptoms can be indicative of several possible causes.
Information of past medical history and family may aid in strengthen a suspect diagnosis, such as coronary artery disease or respiratory disease in the same family may indicate prevalence. However, Mavis did not have any previous medical history, there were no drug allergy history although her father was a heavy smoker and suffered from emphysema and he died of lung cancer 10 years ago. Retrospectively, this event may have impacted Mavis avoidance of seeking medical advice, despite 5 years’ history of experiencing shortness of breath.
When the physical assessment phase of the assessment began, it was noted that Mavis became slightly breathless and this was possible may be due to the time she spent walking up the stairs before coming into the consultation room. There were no signs of cyanosis, or oedema of her extremities. Although Mavis was breathlessness, she seemed comfortable and not appeared to be in distress.
General: Alert and oriented, in no apparent distress.
On examination Mavis was apyrexial, raised of body temperature, she did not show any signs of shock her pulse rate of 80/min, blood pressure of 125/80 mmHg, and respiratory rate of 17/min, her oxygen saturations on air were 98%. Her height 165cm and weight 59kg. Her peak flow was 280L/min which is 75% predicted value. She has no evidence of weight loss as it can be caused by malignancy, chronic infection such as tuberculosis or HIV. There was no evidence of
peripheral oedema.
HEENT: Normocephalic, atraumatic, sclera anicteric. Mucus
membranes are moist.
On inspection of Mavis neck and chest area, there was tracheal
deviation and asymmetry of chest shape. There no complaint of tenderness on palpation of the ribs and sternum. Chest expansion symmetrical, however, there was slight bilateral decreased in chest expansion.
Though, Mavis’ finger nails have signs of clubbing, her nails are yellow stained which indicative of her being a heavy smoker. Evaluation of cigarette stains as a marker of tobacco related diseases, the development of stains independent of the cumulative exposure to smoking.
Mavis’s conjunctiva and mucosa areas are pink, as pallor of conjunctivae, nail beds, palmer creases and face are pallor.
There was slight diffuse hyper-resonant. On auscultation it revealed there was reduced breath sound on both sides of Mavis chest. No adventious sounds heard. No chest pain, no haemoptysis, no night
sweat, no fever, no chest pain, no increased respiratory rate and
pulse rate.
Abdomen: moderate tenderness to palpation in the right lower
quadrant without rebound, guarding, or rigidity. Bowel sounds are
present throughout. Negative psoas and obturator signs.
Genitourinary (GU): genitalia examined in standing position with a
normal external exam, no masses felt with a cough, intact
cremasteric reflex
Back: No cerebrovascular (CVA) tenderness
Neurological: No focal deficits
Skin: Warm and dry, no rashes
1. WhataretheabnormalfindinginMsMavis?
2. Discuss yours analyze for each one?
3. What are the normal finding for each one?
The Case for health assessment:
Chief Complaint: Mavis is a 55-year-old female was seen by her GP due to a chest infection, she was given a course of antibiotic and she was advised to return to the surgery for a follow up. Although she completed her prescribed treatment, she was still complaining of shortness of breath and chest tightness.
History of Present Illness: Mavis has been having symptoms of shortness of breath and chest tightening for over five years with little or no variations in her symptoms, but she tends to feel worse in the morning and in cold, damp or windy conditions. However, the timing of her breathlessness symptoms can be indicative of several possible causes.
Information of past medical history and family may aid in strengthen a suspect diagnosis, such as coronary artery disease or respiratory disease in the same family may indicate prevalence. However, Mavis did not have any previous medical history, there were no drug allergy history although her father was a heavy smoker and suffered from emphysema and he died of lung cancer 10 years ago. Retrospectively, this event may have impacted Mavis avoidance of seeking medical advice, despite 5 years’ history of experiencing shortness of breath.
When the physical assessment phase of the assessment began, it was noted that Mavis became slightly breathless and this was possible may be due to the time she spent walking up the stairs before coming into the consultation room. There were no signs of cyanosis, or oedema of her extremities. Although Mavis was breathlessness, she seemed comfortable and not appeared to be in distress.
General: Alert and oriented, in no apparent distress.
On examination Mavis was apyrexial, raised of body temperature, she did not show any signs of shock her pulse rate of 80/min, blood pressure of 125/80 mmHg, and respiratory rate of 17/min, her oxygen saturations on air were 98%. Her height 165cm and weight 59kg. Her peak flow was 280L/min which is 75% predicted value. She has no evidence of weight loss as it can be caused by malignancy, chronic infection such as tuberculosis or HIV. There was no evidence of
peripheral oedema.
HEENT: Normocephalic, atraumatic, sclera anicteric. Mucus
membranes are moist.
On inspection of Mavis neck and chest area, there was tracheal
deviation and asymmetry of chest shape. There no complaint of tenderness on palpation of the ribs and sternum. Chest expansion symmetrical, however, there was slight bilateral decreased in chest expansion.
Though, Mavis’ finger nails have signs of clubbing, her nails are yellow stained which indicative of her being a heavy smoker. Evaluation of cigarette stains as a marker of tobacco related diseases, the development of stains independent of the cumulative exposure to smoking.
Mavis’s conjunctiva and mucosa areas are pink, as pallor of conjunctivae, nail beds, palmer creases and face are pallor.
There was slight diffuse hyper-resonant. On auscultation it revealed there was reduced breath sound on both sides of Mavis chest. No adventious sounds heard. No chest pain, no haemoptysis, no night
sweat, no fever, no chest pain, no increased respiratory rate and
pulse rate.
Abdomen: moderate tenderness to palpation in the right lower
quadrant without rebound, guarding, or rigidity. Bowel sounds are
present throughout. Negative psoas and obturator signs.
Genitourinary (GU): genitalia examined in standing position with a
normal external exam, no masses felt with a cough, intact
cremasteric reflex
Back: No cerebrovascular (CVA) tenderness
Neurological: No focal deficits
Skin: Warm and dry, no rashes