I need help Creating the map below with information given. Health Care Practitioner note: CHIEF COMPLAINT: "I have had t
Posted: Tue Feb 15, 2022 3:51 pm
I need help Creating the map below with information
given.
Health Care Practitioner note:
CHIEF COMPLAINT: "I have had trouble breathing for the past 3
weeks"
HISTORY: 65-year-old Caucasian male complaining of shortness of
breath and productive cough with yellow sputum for 3 weeks. He also
states that he has been coughing accompanying with low-grade type
fever. He also admits to having intermittent headaches and
bilateral chest pain that does not radiate to upper extremities and
jaws but worse with coughing. Patient initially had this type of
episodes about 10 months ago but has intermittently getting worse
since. PMH: Asthma, Bronchitis PSH: none FH: Non-contributory SOCH:
Married and lives with wife, Mary, retired postal worker, has 3
children, 7 grandchildren. 100 packs/years and is a social drinker.
He denies any illicit drug use.
TRAVEL HISTORY: Denies any recent travel overseas
ALLERGIES: Sulfa
HOME MEDICATIONS: Albuterol 2 puffs bid prn. REVIEW OF SYSTEMS
REVEALS: Same as above
PHYSICAL assessment: Vital signs are: Temp. 98 F / BP 126/82,
Resp. 26, P 88 General: Patient is cachetic, anxious in mild acute
respiratory distress. Lips are cyanotic. He denies fever, night
sweats
HEENT: Head: Atraumatic, normocephalic, Eyes: Conjunctiva clear;
pupils 3 mm in size, EOMI, PERLLA Ears: Tympanic membranes are
pearly gray; no TM inflammation or perforation. Nose: Nasal
congestion with thick yellow rhinorrhea; swollen, erythematous
nasal turbinates; septum midline Throat: Pharyngeal erythema;
post-nasal drainage; tonsils mildly enlarged; there are no
pustules, ulcers or exudate.
Face: Symmetrical; no maxillary or frontal sinus tenderness
Neck: Supple, no anterior or posterior cervical lymphadenopathy;
thyroid is not palpable; trachea is midline; no JVD
Heart: regular rhythm; normal S1 and S2; no S3 or S4; no
murmurs, gallops or rubs.
Lungs: with rapid respirations, marked supraclavicular and
intercostal retractions, using his accessory muscles to breath.
Bi-basilar crackles left > right, diffuse wheezes.
Chest assessment revealed limited expansion, increased A-P
diameter, hyperresonance and a fixed diaphragm on percussion,
marked inspiratory and expiratory wheezing, and a prolonged
expiratory phase.
Abdomen: No distention; no tenderness to palpation; no masses or
organomegaly; bowel sounds present in four quadrants; no bruits
auscultated; no inguinal adenopathy.
Extremities: Warm, strong pulses throughout. No clubbing or
edema.
Neuro: Moving all extremities well, 2+/4 reflexes
throughout.
OSTEOPATHIC STRUCTURAL : He has bilateral paravertebral spasm,
greater on the right, T10-L5. The spine is flattened T10-L2.
Generalized restriction of the lumbar to spring towards rotation
and side bending both directions. Restriction to extension
(restriction to anterior spring) T10-L3. Articular restriction is
greatest T10-12. T4 ESrRr, T2 FSlRl. Twelfth ribs held in
exhalation at an extremely acute angle static with respiration.
Ribs 8-10 are held in inhalation bilaterally. 1st and 2nd ribs are
elevated on the right with right clavicle elevated. The left 2nd
rib is held in exhalation and there is bogginess to the tissues in
the area of the second ribs. The thorax has general restriction to
exhalation. The diaphragm was extremely tense and depressed with
virtually no discernable movement during respiration.
ASSESSMENT: Exacerbation of COPD related to respiratory
infections.
PLAN: Treat with antibiotics and observe for improvement in
status. Discharge home
chief complaint: productive cough and shortness of breathe
Admission diagnosis: COPD
Signs and Symptoms Outcomes Medical Dx/ Reason for Admission/history/Age Short Term Goal Objective Age 65 Long Term Goal Past Medical History Subjective "I have had trouble breathing for the past 3 weeks" Reason for Admission Trouble breathing Evaluation Nursing Diagnosis Nursing Interventions/ Rationales Nursing Interventions Assess: Rationales for Nursing Interventions Assess: Do: Do: Teach: Teach: Ref:
given.
Health Care Practitioner note:
CHIEF COMPLAINT: "I have had trouble breathing for the past 3
weeks"
HISTORY: 65-year-old Caucasian male complaining of shortness of
breath and productive cough with yellow sputum for 3 weeks. He also
states that he has been coughing accompanying with low-grade type
fever. He also admits to having intermittent headaches and
bilateral chest pain that does not radiate to upper extremities and
jaws but worse with coughing. Patient initially had this type of
episodes about 10 months ago but has intermittently getting worse
since. PMH: Asthma, Bronchitis PSH: none FH: Non-contributory SOCH:
Married and lives with wife, Mary, retired postal worker, has 3
children, 7 grandchildren. 100 packs/years and is a social drinker.
He denies any illicit drug use.
TRAVEL HISTORY: Denies any recent travel overseas
ALLERGIES: Sulfa
HOME MEDICATIONS: Albuterol 2 puffs bid prn. REVIEW OF SYSTEMS
REVEALS: Same as above
PHYSICAL assessment: Vital signs are: Temp. 98 F / BP 126/82,
Resp. 26, P 88 General: Patient is cachetic, anxious in mild acute
respiratory distress. Lips are cyanotic. He denies fever, night
sweats
HEENT: Head: Atraumatic, normocephalic, Eyes: Conjunctiva clear;
pupils 3 mm in size, EOMI, PERLLA Ears: Tympanic membranes are
pearly gray; no TM inflammation or perforation. Nose: Nasal
congestion with thick yellow rhinorrhea; swollen, erythematous
nasal turbinates; septum midline Throat: Pharyngeal erythema;
post-nasal drainage; tonsils mildly enlarged; there are no
pustules, ulcers or exudate.
Face: Symmetrical; no maxillary or frontal sinus tenderness
Neck: Supple, no anterior or posterior cervical lymphadenopathy;
thyroid is not palpable; trachea is midline; no JVD
Heart: regular rhythm; normal S1 and S2; no S3 or S4; no
murmurs, gallops or rubs.
Lungs: with rapid respirations, marked supraclavicular and
intercostal retractions, using his accessory muscles to breath.
Bi-basilar crackles left > right, diffuse wheezes.
Chest assessment revealed limited expansion, increased A-P
diameter, hyperresonance and a fixed diaphragm on percussion,
marked inspiratory and expiratory wheezing, and a prolonged
expiratory phase.
Abdomen: No distention; no tenderness to palpation; no masses or
organomegaly; bowel sounds present in four quadrants; no bruits
auscultated; no inguinal adenopathy.
Extremities: Warm, strong pulses throughout. No clubbing or
edema.
Neuro: Moving all extremities well, 2+/4 reflexes
throughout.
OSTEOPATHIC STRUCTURAL : He has bilateral paravertebral spasm,
greater on the right, T10-L5. The spine is flattened T10-L2.
Generalized restriction of the lumbar to spring towards rotation
and side bending both directions. Restriction to extension
(restriction to anterior spring) T10-L3. Articular restriction is
greatest T10-12. T4 ESrRr, T2 FSlRl. Twelfth ribs held in
exhalation at an extremely acute angle static with respiration.
Ribs 8-10 are held in inhalation bilaterally. 1st and 2nd ribs are
elevated on the right with right clavicle elevated. The left 2nd
rib is held in exhalation and there is bogginess to the tissues in
the area of the second ribs. The thorax has general restriction to
exhalation. The diaphragm was extremely tense and depressed with
virtually no discernable movement during respiration.
ASSESSMENT: Exacerbation of COPD related to respiratory
infections.
PLAN: Treat with antibiotics and observe for improvement in
status. Discharge home
chief complaint: productive cough and shortness of breathe
Admission diagnosis: COPD
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