SOLVED512

Tekla, age 58, has reported to the clinic as a follow-up of primary care post-hospitalization. Case Tekla’s breathing is slightly labored on exam, with a respiratory rate of 18 breaths per minute. He appears pale and anxious. Tekla’s heart rate is 86 beats per minute, and his blood pressure, with anti-hypertensive medications, is 158/88 mm Hg. Tekla complains that he has been having problems breathing, especially at night, and must sleep “propped up.” Tekla is from Addis Ababa and has lived in the US for 18 years when he came to join his daughter and son-in-law. He was diagnosed with hypertension 14 years ago. Tekla’s medication review: HCTZ 25 mg Q day Omeprazole 20 mg Q day OTC States he’s been taking both meds since being discharged Auscultation reveals the presence of pulmonary crackles. ECG and echocardiogram results indicate left ventricular hypertrophy. In addition, jugular vein distention, peripheral edema, and enlargement of the liver are noted. Questions Physical Assessment: 1. What are pulmonary crackles? 2. What is JVD and its significance in this exam? 3. How do you evaluate hepatic enlargement? 4. What would the S section of Tekla’s SOAP note look like? 5. How important are weight and edema
SCIENCE
HEALTH SCIENCE
NURSING

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