Health assessment discussion 4

Case 1

Chief Complaint (CC) 

A 65-year-old male with chronic obstructive pulmonary disease (COPD) presents to the clinic with a cough he has had for the past 2 weeks.

Subjective

denies chest pain, denies night sweats, admits to having a fever but does not know the temp.

 VS

(BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air.

 General

patient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5′3″; weight 175 lbs

 HEENT

EYES: no injection, no increase in lacrimation or purulent drainage; EARS: normal TM: Normal NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Obstructed air passages

 Respiratory

lung crackles in LLL, no wheezes or rhonchi noted; does not clear with coughing; dullness to percussion over the LLL; shallow respirations and is 30, accessory muscles use not present

Neck/Throat

no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged; trachea midline

Heart

Regular rate and rhythm, no murmur, S3, or S4