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Today you are off from the clinic and are covering a shift in the emergency room department.    

Question
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Asked by fuzzydaisy593

Today you are off from the clinic and are covering a shift in the emergency room department.  

 

You go to see Mr. ABC a 34-year-old Hispanic male who presented with a compliant of severe dyspnea.  He has been experiencing dyspnea for 2 weeks that has slowly, but progressively gotten worse.  He was brought back immediately from triage because he has a respiratory rate of 40, an 02 sat of 88%, and a temperature of 101.  His o2 sat has improved 92%  on 4 Liters of oxygen via N.C.  

 

Review of symptoms is positive for fever, chills, weight loss, malaise/fatigue, diaphoresis, cough, dyspnea, weakness, swelling in his lower extremities, feeling of abdominal fullness, and unintentional weight loss.  He denies any other symptoms.  

 

Past medical History includes Asthma. 

Past surgical history, none.  

Social history, single male, has sexual relations with men and women, denies smoking use.  Has a history of iv drug use but has not used for 5 years and used to be a heavy drinker for 10 years.  He has not drank for 2 years.

 

Physical Exam

Vital signs: temp 101, heart rate 120, resp rate 38 blood pressure 110/60, o2 sat 92% on 4 liters N.C.

Constitutional: Alert and oriented x 3. Thin.

Head: Normocephalic and atraumatic

Eyes: Pupils are equal, round, and react to light. No nystagmus. No scleral icterus.

Oropharynx: White patches on tongue and buccal mucosa bilateral

Neck: neck supple. No JVD present. No tracheal deviation present. No thyromegaly or thyroid nodules noted.

Cardiovascular :Normal rate, S1 normal, S2 present, without S3, S4 gallop, friction rub or murmur. 1+ pitting edema to lower extremities.

Pulses: brachial, radial, dorsalis pedis, and posterior tibial pulses are 2+/4+ bilaterally.

Pulmonary/chest: Dyspneic. Respirations regular and even.  Lungs have rales in all lung fields.

Abdominal: round, distended, soft.  Bowel sounds are active. No mases noted. No CVA tenderness. Hepatosplenomegaly present. Shifting dullness. There is no rigidity, rebound, or guarding.

Lymph: has widely spread lymphadenopathy.

Neurological: Cranial Nerves 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 notrmal. Calm and cooperative behavior. Judement intact.

 

ABC’s Questions — Upon completing 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.  Your response should demonstrate that you are speaking with Mr. ABC as though you were in the room with him.
Based on the current information available, what are 2-3 possible diagnosis this patient has? While your diagnosis still need to be confirmed, you have enough information to know what is wrong with Mr. ABC.
What labs and/or diagnostic tests do you believe are needed to confirm your diagnosis?
Describe the pathogenesis which explains the patient’s condition?
What education is important for Mr. ABC to receive?
SCIENCE
HEALTH SCIENCE
NURSING
NUR 5315

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