Patient F. F Case Study

HPI (History of Present Illness): The patient is a 65-year-old Caucasian female with symptoms of dry cough for the past two weeks, low grade fever for two days, and decreased appetite that have been deteriorating with time. She also experiences shortness of breath (SOB) with activity. She was treated for similar symptoms three months ago with antibiotics and an inhaler and some improvement was noted in her condition. At the moment she is seeking medical attention as she is concerned about her fever and prolonged illness.

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

This is a 50 years old male with no significant past medical history presented initially with shortness of breath and hypoxia and was transferred to the ICU. He was treated for bilateral pneumonia that required prolonged mechanical ventilation via a tracheostomy. He has necrotizing pneumonia and he has been in the hospital for 6 weeks due to the development of multi-organ failure. He was weaned from mechanical ventilation to the point he was tolerating a CPAP/PS mode. Later on, it was noticed that he

This is 51 year old AAF. Patient is here complaining of several issues as listed. Patietn reports for the past several days she had increased SOB at rest, non-productive cough, adiouble wheezes. Patient denies chest pain, N/V/ D. Patient is a current tobacco user wit 20 pack year hisotyr. Denies use of alcohol or illicit drug use. Denies depressive moods, current pain 3/10.

I started my morning by reviewing his Kardex and noticed that chest pain had been noted and that he had an ECG and CT of his chest. I went into his room to find him wide-awake in bed. I performed my safety check and took his vitals. His resp rate was quite high at this time and his Sp02 was on the lower side. MK expressed through nodding that he was having chest pain during that time. I also did a respiratory assessment because I was concerned with his SpO2 and resp rate. I found decreased air entry to his bases, expiratory wheeze, and a visual use of accessory muscle to breath. His breathes where short and labored. When asked if he was experiencing SOB, he nodded and this directed my care for that morning. I reported to my instructor with my findings as this was the first time I had a client say yes to chest pain. I quickly addressed his SOB with his PRN bronchodilator using a spacer and put him on two liters of O2 via nasal prongs. I checked back in after 5 minutes and his resp rate had lowered and his SpO2 had risen to a more adequate level. I noticed he did not have audible wheeze any longer and was not using his accessory muscles. Overall he looked way more relaxed in his bed after addressing his respiratory distress. Unfortunately, he still was nodding yes to chest pain in that moment. The RN on my team left a doctors note about another CT and ECG and noted that the client was still

His lung sounds are diminished bilaterally. Pulse oximetry reading is 90%. He is receiving oxygen at 2 liters per nasal cannula. He complains of shortness of breath with exertion.

Respiratory: Patient denies having history of lung diseases such as asthma, emphysema, bronchitis, pneumonia, or tuberculosis. She also denies having chest pain with breathing, wheezing or noise breathing, shortness of breath, hemoptysis, sputum, toxin or pollution exposure. Patient states that she had common cold with some productive cough for about a week last month. Also, patient states that occasionally she experiences shortness of breath when she runs for more than 40 minutes. Patient states that her last chest x-ray was 1 years ago, and the results were negative.

The patient is a 74-year-old female who was brought to the emergency room by BLS when she awakened from sleep with severe shortness of breath. In transit she received sublingual Nitroglycerin note to supplementation as well as a nebulizer. When seen in the ED she was placed on BiPAP and nebulizer for approximately an hour. It is to be noted the patient has severe COPD and pulmonary hypertension. She does have coronary disease as well. It is to be noted that she is on Citrucel for her pulmonary hypertension. There are no blood gases done, however on BiPAP her O2 sats were 99%. Chest x-ray shows soft tissue mass I believe in the right upper lobe. I believe that this patient in view of her significant history of comorbidities and severe

History of Present Illness: Recurrent episodes of shortness of breathe and productive cough since 2008. First episode occurred when she was in her early 80’s. She was awakened in the middle of the night with a very

The patient’s physical examination upon admittance (11/30/14) revealed the patient awake, alert and orientated x3; she was in some apparent distress but was not found to be in any pain. Auscultation of the lungs conceded adequate air entry bilaterally with bilateral rhonchi. The lower extremities showed pedal edema but with no signs of a deep vein thrombosis in the legs. Examination of the head, eyes, ears, nose and throat (HEENT) showed pink and moist oral mucosa. The pupils were equal and reactive to light.

Patient was seen almost 24 hours ago here with shortness of breath. Advised then of worsening CHF and advised strongly to be transferred to such a place as UVA for continued and more complex care. He declined that, was given Lasix IV felt better left against medical advice. Was advised to return any time. Then approximately 7:30 p.m. about eight hours ago, he attempted to go to bed found himself more and more dyspneic from then to present. Found he could not rest. More difficulty lying down and great dyspnea on any exertion and returned as advised for further care by ambulance. He has had no chest pain. No fever. No cough.

This is a 62-year-old female who required inpatient hospitalization due to ride-sided empyema. She was transferred from another inpatient facility to Mercy San Juan due to complaints of shortness of breath accompanied by cough and chest pain. Prior to admission, she had a chest x-ray that showed patchy right lower lobe opacity that represents pneumonia and pleural effusion. Moreover, her CT chest revealed right lower lobe pulmonary necrosis in the medial right lower lobe and pleural effusion with right middle lobe atelectasis. She received azithromycin and Rocephin and was evaluated by the Pulmonologist. Her past medical history is significant for COPD and Hyperlipidemia. Vital signs included of a blood pressure of 144/77 mmHg and an oxygen

The patient manifested signs of respiratory distress precipitated by a pneumonia and bronchiolitis infection. A.D was on 0.5 liters of oxygen via nasal prongs with an oxygen saturation reading of 94%. On prior days without the supplemental oxygen, she was desaturating to below 92%, “ high flow rates generate continuous positive pressure in the airways that could help reduce the work of breathing in bronchiolitis and decrease the need for more invasive respiratory support” (Casey, 2015, p. 24). The patient had a respiratory rate of 42 breaths per minute and the normal respiratory rate for a 13month old as stated in Perry et al. (2013) ranges between 20-40 breaths per minute. Also, the patient had a heart rate of 158 beats per minute and the

The patient is a sixty-seven-year-old Somali female, whom will be referred to as Jane. Jane initially presented to the emergency room with shortness of breath, fever, tachycardia, and a persistent cough. She has a history of tachycardia and asthma. The goal for the treatment of this patient was to rule out avian flu, and to manage her tachycardia and asthma.

Ran-hui et al. (2016) explains that the patient made complaints about myalgia, dyspnea, dry cough as well as vomiting as a result of continued nausea. All these symptoms were identified from the primary examination that was done at the time of admission. Some of the vital signs that the patient appears included an extremely high pressure, which was measured to be about 135/72mmHg; a peak body temperature that was measured to be 38.60C (Hamzah, Jaffar, and Ziad, 2016). At the same time, the heartbeat of the patient was measured to be about 85/minutes with a respiration rate of 20/minute (Ran-hui et al., 2016). The primary diagnosis of the patient also indicated a measure test that showed an albumin and blood at negative/negative. Ran-hui et al. (2016) says that there were also multiple pneumonic infiltrations that were located in the middle and upper lobes and also in the left lower lobe that were taken on the chest radiography. According to Hamzah, Jaffar, and Ziad (2016), the doctors treated the patient by administering 180 μg of pegylated interferon-alpha on hospital day (HOD) 1 and 1,800 mg of ribavirin (600 mg every 8 hours) daily from HOD 3 to HOD 7. This process also led to a discontinuation of anti-viral treatments because of thrombocytopenia (lowest platelet count was 56,000/μL) and sustained fever that the patient was still complaining about (Ran-hui et al., 2016). In managing the conditions that the patient was suffering from, the doctors placed him on a mechanical ventilator on HOD 4. This was also followed by the increased multiple pneumonia infiltrations that were always identified. To stabilize the patient further, the doctors decided to undertake a tracheostomy on the HOD 23, which had the effect of weaning the patient from the mechanical ventilator HOD 39, which the patient had been given. From all these numerous tests that were conducted, it was found that