SOLVED21

HPI: 42 year old male, John A., complains of “aching in the chest” from coughing. He said he has had the cough for a little over a week now and it is not getting any better. He has tried OTC Robitussin Cough with minimal relief. He says that the cough started as a dry cough, but now has some yellow productive sputum. John said that he has cut down his smoking considerable because of the coughing. He says, “I thought this was a cold at first, but when the cough started and got worse, I became concerned.” He says that the night time is the worst for the cough and when he wakes he sometimes has some dark sputum. He says he has a fever on and off with some sweating, fatigue, and SOB on exertion. PMHx: GERD, URI and Bronchitis in the past. No previous hospitalization. Immunizations are UTD; Flu vaccine annually, Tetanus was updated about 3 years ago, COVID-19 Pfizer vaccine completed 8 months ago. PSHx: T&A as a child. FHx: Mother age 72 is alive and healthy, Father age 74 and has hx of COPD, HTN and Hyperlipidemia, Maternal Grand Mother deceased at age 94 from natural causes, Maternal Grand Father died at age 90 from pneumonia, Paternal Grand Mother deceased at age 95 from natural causes, Paternal Grand Father deceased at age 96 from natural causes. SoHx: Single, lives alone. Works in a factory making car parts, Smokes ½-1ppd for the past 20 years, has tried to stop smoking several times. Drinks socially, does not use any recreational or illegal drugs. Has several female intimate partners and uses contraception “sometimes.” Allergies: NKDA, no environmental allergies. Medications: Vitamin D 2,00 IU daily, Omeprazole 20mg every morning, Robitussin 12-hour Cough 1 tsp twice a day for the cough • Based on the above information, what are the systems that you would include on the review of systems? Review of Systems: General: Denies any weight loss, appetite is less than normal because of the cough, Patient reports that he does have a fever of 99-100 F sporadically with some fatigue. Chest: Chest wall “ache” secondary to the cough. Lungs: Patient complains of anterior wall chest “ache” from frequent coughing. SOB with exertion. Denies any wheezes, stridor, hemoptysis, or night sweats. Reports a productive cough that produces dark sputum in the morning otherwise is yellow. Pt has hx of URI and Bronchitis in the past, last episode was 2 years ago. CV: Denies any chest pains, radiating pain to the arms or neck. Denies any palpitations or syncopal episodes. Denies any claudication, varicose veins. Denies any hx of CV disease. GI: Patient has a hx of GERD and uses PPI to control. Denies any dysphagia, abdominal pain, nausea, vomiting, hematemesis. Denies any diarrhea, constipation, blood in stool, hemorrhoids or changes in bowel pattern. • Based on the information given, what are the systems you would include in the Objective portion for exam and why? O: PE VS T 99.0 F, RR 20, HR 102, BP 140/88, SpO2 93%, Ht. 72″ Wt. 195# BMI 26 General: WDWN, appropriately dressed, appearing good hygiene, denies any weight gain or weight loss, appetite is less than his usual. Chest: Chest wall is tender to anterior palpation of the chest wall. There is no supraclavicular lymph nodes appreciated. Lungs: AP diameter is 2:1, respirations are tachypneic, lungs have decreased breath sounds with course breath sounds in the bases to auscultation anterior and posteriorly. Percussion is dull over the lower lobes bilaterally. Positive bronchophony and whispered pectoquilery, anteriorly and posteriorly in the lower lobes bilaterally. CV: S1 and S2 are intact, heart rate is tachycardic, no rubs or murmurs appreciated. GI: There is no distention on inspection of the abdomen. No scars or lesion. Bowel sounds are present in all four quadrants by auscultation, Percussion is tympanic in all areas. Liver boarder is percussed to 6cm boarder, liver is not palpable. There is no abdominal tenderness to palpation in all areas. There is no tenderness in the epigastrium to palpati
SCIENCE
HEALTH SCIENCE
NURSING

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