Today you are off from the clinic and are covering a shift in the emergency department. You go to se. Question
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Asked by GeneralRain7180
Today you are off from the clinic and are covering a shift in the emergency department. You go to see Mr ABC, a 34 -year old Hispanic male who presented with complaint of severe dyspnea. He has been experiencing dyspnea for 2 weeks that has slowly, but progressively gotten worse. He was brought back immediately from traige because he has respiratory rate of 40, an 02 sat of 88% and a temperature of 101. His 02 sat has improved 92% on 4L of oxygen via NC.
Review of the symptoms is positive for fevers, chills, weight loss, malaise/fatigue, diaphoresis, cough, dyspnea, weakness, swelling in his lower extremities, feeling of abnormal fullness, and unintentional weight loss. He denies any othe symptoms.
Past Medical History: Asthma
Past surgical History: None
Social History: Single Male, has sexual realtions with men and women, denies smoking use. He has a history of IV drug use but has not used for 5 years and used to be a heavy drinkers for 10 years. Has not drank for 2 years.
Physical exam:
Vitals: 101-120-38-110/60, 92% on 4L NC
Constitutional: Alert and oriented x3. Thin.
Head: Normocephalic and atraumatic
Eyes: Puplis equal, round and recative to light. No Nystagmus. No scleral icterus
Oropharynx: White patches on tongue and buccal mucosa bilaterally
Neck: Neck supple. No JVD present. No tracheal deviation present. No Thyromegaly or thyroid modules noted.
Cardiovascular: Normal rates, S1 Normal, S2 present, without S3, S4, gallop, friction rub or murmur. 1+ pitting edema in lower extremities.
Pulses: Brachial, Radial, Dorsalis pedis, and posterior tibial pulses 2+/4+ bilaterally
Pulmonary/Chest: Dyspneic. Respirations regular and even. Lung have rales in all lung fields.
Abdominal: Round, distened, soft. Bowel Sounds are active. Generalized tenderness. no mass noted. No CVA tenderness. Hepatosplenomegaly present. Shifting dullness. There is no rigidity, rebound or guarding.
Lymph: Has widely spread lymphadenopathy
Neurological: CN II-XII intact
Skin: Skin is warm, dry and intact. A line of vesicles on the left thorax that extends from the anterior to posterior Thorax.
Psychiatric: Mood and affect normal. Calm and cooperative behavior. Judgment intact.
Upon completeing the history and physical Mr. ABC asks you: ” What is wrong with me? Why am I sick? What do I need to do to get better?” Your objective is to answer Mr. ABC’s questions. To answer his questions completely, you must integrate the answers to the questions below into your response to Mr ABC.
1. Based on the current information available, what diagnoses do you beleive Mr. ABC has? While your diagnoses still need to be confirmed, you have enough information to know what is wrong with Mr. ABC.
2. What labs and/or diagnostics tests do you beleive are needed to confirm your diagnoses?
3. Describe the pathogenesis which explains this patient condition?
4. What education is important for Mr. ABC to receive?
SCIENCE
HEALTH SCIENCE
NURSING
NURS 5315
Today you are off from the clinic and are covering a shift in the emergency department. You go to se
