module 8

Respiratory Patient Case

Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a musculoskeletal problem, but please use the following basic information to document about your patient:

Subjective Data:

Mr. Zhang, a 68-year-old Chinese man

Chief Complaint: shortness of breath and fatigue.

Current smoker: 98 pack-year history of smoking

Past medical history: high blood pressure and COPD.

Medications: thiazide diuretic, chlorthalidone, for his high blood pressure. Albuterol and ipratropium inhalers for breathing.

Allergies: pollen and latex.

History of past Illness (HPI): States he has increase in shortness of breath recently. He also says he is coughing “stuff up”

Ask Mr. Zhang more PQRTSTU about his symptoms.

Physical Exam (objective data):

Vital Signs: Oral Temp 100 F, HR 112 BPM, RR 24, and BP 156/78 mm Hg, SpO2 88%

Inspection: Anteroposterior (AP) diameter to the Transverse (T) diameter ratio is 1:1. Skin color pale, using accessory muscles to breathe. Clubbing present in fingers. Coughing up moderate amounts of thick-yellow sputum. Other inspection document as normal/expected findings

Palpation: Tactile fremitus increased right bases anteriorly and posteriorly. Document rest of palpation as normal/expected findings

Auscultation: Crackles in right lower lobe. Positive bronchophony and whispered pectoriloquy over right lower lobe. Positive E to A change present over right lower lobe. Document rest of auscultation as “normal”

Two actual or potential Risk Factors

1. Mr. Zhang is at risk for … because the assessment findings indicated ……

2. Mr. Zhang is also at risk for … because the assessment findings indicated that…..