The patient is alert and oriented to person, place, and time. Upon initial interaction, the patient is easy to communicate with and states she is doing well. Facial features are uneven and asymmetrical, as she has a slight left facial droop due to her stroke, which she states happened a couple of years ago. DG expresses multiple times that she has a hard time seeing and she wears prescription eyeglasses. PERRLA. Skin is pink, warm, dry; temperature is 97.5 and turgor is brisk. There is a 20 gauge IV in the right hand infusing Lactated Ringers at 20ml/hour per pump, no redness or edema noted at the insertion site. Respirations are even and non-labored at 22 breaths per minute. Lung sounds are bilaterally clear. The client has a nasal cannula infusing 2 liters of oxygen with an oxygen saturation of 96%. DG tells me she is a current smoker and she smokes
According to the provider, the claimant's cough has been improved. His review of systems was positive for fatigue, malaise, sleep difficulty, shortness of breath, wheezes, and a cough. His blood pressure was 115/71 mmHg and his BMI was 30.35 kg/m2. The physical examination revealed wheezes. Clonazepam was prescribed for agitation. Atorvastatin, Nystatin, Citalopram, and a probiotic were prescribed. Continued use of Aspirin and a regular inhaler were suggested. Further, a follow-up visit with Endocrinology, Cardiology, and Pulmonology. As it relates to a spot in his lung, a repeat CT scan was recommended. The bronchial washes were negative for
Peripheral pulses posterior tibial and dorsalis pedis 2+ bilaterally. No edema on legs. Apical pulse regular rate and rhythm; s1, s2 noted. No murmurs, rubs or gallop rhythms. Denies dizziness, and fainting. Resp RR between 36-40 SpO2 85% per oximetry on 2 liters oxygen by n/c. Difficulty breathing and complaints of chest tightness. Patient unable to lay flat. Lung sound bilateral wheezes and crackles in right lower lobe. All other lobes clear A&P. Cough with yellow sputum. Tachypnea. Head of bed 45 degree. GI Last bowel movement 2 days ago, hard, long brown stool. Complains of constipation related to medication. Bowel sound are WNL in all 4 quadrants. Abdomen is soft, with no palpable masses. Poor appetite. Like sweet foods. Does not like vegetable or fruits. Like sodas, beer, scotch. Little water intake. GU Urinates every 2-3 hours. Yellow. No odor of urine. No history of UTI. One vaginal infection 2 years ago. No abnormal periods, last menstrual period 3 weeks ago. No pain or discharge. Skin Hair poorly groomed, dirty and oily. Nail are dirty and appear to be bitten. Skin clammy and moist with flushed color. IV IV of D5W at 125 mL in left forearm with 18
Patient “DD” is a 56-year-old woman who was admitted to a nearby hospital for respiratory failure. With the only previous medical history being chronic bronchitis, she was diagnosed upon admission with COPD, anemia, hypoxia, moderate anxiety, and dyspnea.
Name: Margaret Elliot DOB: 1/22/65 Sex: Female Date: 1/22/65 CC: “severe shortness of breath” HPI: Margaret Elliot is a 52-year-old Caucasian female that is presenting with shortness of breath that has recently worsen. Mrs. Elliot states that her problems began 20 years ago when she had bronchitis, which she consistently has 2-3 times a year. She said that her symptoms have been getting worse the last 2.5 month, but have severely worsen over the past three days. She states that it has been restricting her daily activities and has been troubling her while sleeping lying down. She states that her symptoms improve alittle when she takes her medications. She also states that her symptoms worsen when she tries to walk across the room
4. A 79-year-old female present with her daughter for ongoing fatigue also noted to have lost 5 pounds over past 6 months. No night sweats or fevers. Pertinent past medical history includes severe, generalized osteoarthritis, hypertension, type 2 diabetes mellitus and depression. She is taking the following medications: acetaminophen 650mg every eight hours, Lyrica 75 mg twice daily; alendronate 70 mg once weekly, valsartan 320 mg once daily, fluoxetine 40mg once daily and insulin glargine 20 units once daily. Your exam reveals slight pale conjunctivae, a 2/6 systolic ejection murmur and generalized arthritic joints in her extremities. A point of care test results in a hemoglobin of 10.2 g/dL. Complete blood cell count is done; results
Subjective S: MJ is a 74 year old African-American female who presents to the clinic today with complaints of shortness of breath with exertion and increasing fatigue over the past two to three months. The shortness of breath is increased with exercise or when walking up stairs and has progressively gotten worse. She states that she presented to the emergency room approximately one year ago for shortness of breath and was prescribed an albuterol inhaler. She additionally has a chronic productive cough with clear sputum and denies hemoptysis. She has had no recent upper respiratory infections and denies fever. She denies chest pain or tightness. She also states that she has noticed some ankle edema over that has developed over the past
Background: ----- Clinic presents a black male 68 years old. Currently experiencing dyspnea and lethargy. For the past week he has been having a increase of difficulty breathing. Complains of alternating periods of sweating and chills. Other symptoms he has been experiencing is a productive cough with expectoration of thick yellow
Nursing Care Plan CLIENT CLINICAL PICTURE Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for " atypical chest pain and hemoptysis". V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x
I have caught up with Lesley-Anne eight months since the last appointment. In the last couple of months she has had a dry cough with some breathlessness, but no obvious wheeze. She is also experiencing some right upper quadrant pain and following the onset of the cough, has developed right lateral chest wall pain with tenderness. I gather she had an injection in the left side, possibly to treat costochondritis.
Chief Complains: “My chest hurts, and I am hard to breathe” History of Present Illness: Mr. XXXX is a 44 years old Caucasian male, a general construction worker who works on a nearby highway for the bridge project, and checked in this urgent care center for complaining of chest pain and shortness of breath (SOB). The chest pain is constant dull and pressure like pain, and started 3 hours ago. The pain is located on the center of chest. He rates the pain 4 out of 10 on a pain scale 0 to 10 while resting. The pain gets worse and increases after eating. He experienced increased chest pain and SOB with simple walking from the parking lot to this office. The pain was not resolved with taking PO 365mg of Aspirin 2 hours ago and resting. He was diagnosed with hyperlipedemia 10 years ago. He is taking medication to manage his high cholesterol level. He denies past history of chest pain, hypertension, and coronary artery disease. He denies any history of heart surgery or cardio artery bypass surgery. He is anxious and fearful for his first chest and SOB. He smokes a half pack a day for past 20 years. He drinks one bottle of bear every evening with meals. He denies taking any herbal medication or illicit drugs. He has been a good appetite. He reported 20 lbs weight gain since his retirement from military. He has an irregular meal time and does not exercise as much as he used to do in the military.
CC Question sinus infection. S The patient is a 59-year-old patient of Karen L. Palmer, DO. She tells me that she is prone to sinus infections. She has not however been treated for one in quite some time. She tells me that she does have some rhinorrhea that occurs in the morning for the past decade or so. She does not use any nasal sprays. She tells me that she was doing quite well until yesterday afternoon when she started having pain in the right side of her face and her upper teeth. She denies any fatigue, no fevers, no postnasal drip, no increase in her rhinitis. She denies any cough. She is a smoker of cigarettes and does desperately want to quit. She did discuss this ready with her primary care physician. The patient denies
Date is 11 June. An 85-year-old female who says that she has been doing relatively good. Memory is a little more problematic, and she has some neuropsychiatric testing lined up for next week. She is breathing good. No chest pain. Notes a little bit of peripheral edema from time to time. Appetite good. She says she is eating too much. Her glucose machine broke, and she has not been monitoring her sugars. Her rheumatoid arthritis is doing quite well, and responded to an increase in methotrexate. She says her rheumatologist does not feel that she needs to come back to him anymore. Lab work is out of date, and we will fix that today.
74 y/o female who presented with worsened shortness of breath and cough. A review of the medical records indicates that she suffers from multiple medical illnesses which include bilateral DVT of lower extremity, chronic COPD and Chronic CHF with low oxygen sat and oxygen dependent. She also suffers from recurrent pneumonia and past medical history of lungs cancer S/P lobectomy. The patient denies pain, reports shortness of breath and poor appetite, she appears cachectic/emaciated with visible muscle wasting.
This is 58 year old white female. She is complains of generalized body aches and pains for the past 2 to 3 days. Patient states her throat and ears are also hurting. Patient is a resident at the Jessie Place and her room mate has been sick. Patient reports some fever. Patient is a current tobacco user denies use of alcohol or illicit drugs. Denies chest pain, SOB, N/V/ D. Current pain