SOLVED148

Case scenario: NAME: CJ – male DOB: 12/12/1967 Allergies: NKDA Dx: To be determined 2 Height= 69 inches Weight= 242 lbs (110 kg) 3 CHIEF COMPLAINT: Client arrived to ER, c/o cough x4 days, tired, feeling sluggish, SOB with exertion, fever, states “Can you get me in and out of here quickly? I just want something for my cough. I hate hospitals.” 4 PMHx: Hypertension since 2011, 5 Obesity, 6 Benign Prostate Hypertrophy (BPH) since 2018 7 MEDICATIONS HISTORY 8 Lisinopril 10mg oral daily since 2015 9 PSHx: Vasectomy 2014 10 Social: Smoke 1/2 PPD x30 years, Alcohol occasionally, States “stressful” work, Travels frequently “Trying to lose weight, diet and exercise” 11 Physical Exam: 12 VS: BP 210/105, HR=92, RR=26, Temp=38.6 C, SaO2=92% on RA. 13 HEENT: Head: Eyes: ; Ears: Nose: ; Throat/Oral: WNL 14 Neuro: A&O x3, answering questions, accurate historian, denies headache or blurred vision, MAE (moves all extremities) equal strength bilat UE/LEs, PERRLA, cranial nerves III-XII intact 15 Respiratory/Thorax: course diminished breath sounds to RML, c/o mild SOB with exertion at rest 2/4 on dyspnea scale, no retractions, + non-productive cough 16 Cardiac: Color flushed checks, skin warm to touch, + slight diaphoretic face and body, +peripheral pulses radial/DP +2 equal bilat., no edema, c/o right chest pain 17 Abdomen: Soft, rounded, obese, + bowel tones x 4 quadrants, non-tender 18 GU: urine: no complaints, reports normal voiding “maybe a little dark urine” and voids once nightly 19 Musculoskeletal: MAE (moves all extremities), equal strength bilat. UEs/LEs 20 Skin: Intact

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STUDENT NAME: NAME of Case Scenario ASSIGNMENT: Case Scenario Clinical Judgme Worksheet RUBRIC
RUBRIC: Exemplary (2 pts) Acc Recognize Cues/ All of the following: Any Analyze Cues **Addresses MOST of the A
e Explain the abnormal findings (including findi assessment findings | top 2 priorities) with with that are… Show more

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 4510

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