S The patient is a 19-year-old gentleman who tells me he has been having a sore throat and congestion for the past two weeks. He was also having a cough that would wake him at night. He states the cough now is better but he continues with copious rhinorrhea and postnasal drip.…
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.…
The 2-D echocardiogram [portable] ordered to rule out any cardiac etiology for respiratory distress. The echo on 3/22/17 showed mild diastolic dysfunction with EF of 58%, small left ventricle chamber and had limited images only. He had repeat labs on 3/30/17, showed normal electrolytes, normal liver enzymes with mildly low albumin [3.1], normal CBC with normal white cell count [9.4] and normal thyroid functions…
300.82 Somatic Symptom Disorder with Predominant Pain and Persistent – Severe V61.03 Disruption of family by separation or divorce V61.10 Relationship distress with spouse or intimate partner V62.29 Other problem related to employment Justification of 300.82 - Somatic Symptom Disorder with Predominant Pain and Persistent – Severe Matt has more than one somatic symtom present that is causing him distress and significant disrution in his daily life. Matt has overal pain, specifcilly absominal pain, and has aches, feels sore, and tired (Criterion A). Matt has not been able to work for 2 years now due to the increase in pain.…
He is awake, alert and oriented. He reports that he was told in the hospital about his diagnosis, but was not told about his prognosis. He is awaiting a call back from Dr Swanson office to schedule a follow up appointment. The daughter reports that the patient is scheduled to see his PCP, Dr Harvey today who will review his records and…
Database and Assessment Table 1 – Physical Nursing Assessment Data GENERAL: Patient is an 88 year-old Caucasian male. Vital signs stable at 97.3°F, 82BPM, 22 breaths/min, 84/54mmHg, 100% on 1.5lL O2, 0/10 pain, patient weight 58kg. SKIN/HAIR/NAILS: Skin was thin and fragile, warm and moist, skin color slightly pale, skin tear on left upper arm measuring 3 inches, no bleeding or pain.…
He is not taking any medication and currently practicing conservative management due to financial problems. The patient is not working. He is an immigrant and married to the locals The patient is alert, conscious and tacypnic. He…
Identifying Information: Client is a 68-year-old Caucasian male from Washington, NC. Client presents to Navigate for individual counseling and meditation group. Appearance (e.g. overweight, dresses appropriately, etc.): Client is overweight and of average height.…
Each of these factors blend into one another. His ineffective airway clearance leads to an obstructed airway and this contributes to his decreased perfusion in his lungs, which is why he experiences restlessness and shortness of breath. All of the factors listed above plus many more result in his progressing COPD and ultimately his decreasing health. Leyshon (2012) promotes palliative care for those who in the terminal phase of the disease. When placing a patient on hospice or palliative care "they are more likely to receive co-ordinated support, including classification of their specific needs, advance care planning discussion, prevention of crisis admissions and a proactive approach to symptom management" (P.…
Often, he has had difficulty breathing and shortness of breath. Any elongated or increased exertion resulted in increased pain in his chest and heart along with dyspnea, mild light-headedness, nausea, and diaphoresis. There was no past data indicating correlation to cardiovascular diseases or heartburn/chest pain. Although, past doctor visits had encouraged him to perform better on his exercise lifestyle habits to prevent heart problems but did not follow up. Also, he had a past history of depression and anxiety coupled with prescribed medications but he has not been taking these recently (this could cause him to go through withdraw and possibly abuse other…
I met with the patient and his family (Karen and Susan), Palliative treatment options, prognosis, plan and goals of care reviewed. The family and the patient's goal is to be discharged home with home health when stable. Palliative care will follow the patient in the outpatient setting when discharged. Case review with nurse Alyson and Dr Dawkins.…
Cushing’s Syndrome Case Study, Manifestations, and Nursing Implications Introduction A 44-year-old male presents with complaints of body malaise and anorexia. He has noticed his attitude going from happy to depressed. He complains of weight gain, bruising easily, and frequent backaches. His arms and legs are thin.…
Subjective Data This is a 65 year old Caucasian female presenting with complaints of a persistent rarely productive cough lasting two weeks; causing shortness of breath, and orthopnea. She has been treated for this cough three month ago in the emergency room. At that time chest x-ray (CXR) revealed hyperinflated lungs suggestive of emphysema. She refused to be treated in the hospital at that time, ad was sent home with an inhaler and antibiotics. She also refused the pulmonary function test.…
He never went to see a doctor. We knew that something was going on with him. When we offered him to go to the doctor but he refused and gave some excuses that he was fine. One day he was in an awful condition where he couldn’t move at all and he decided to see a doctor. However, it was too late because he had last stage cancer.…
He could not talk without an effort to breath and took a lot of effort to have a conversation with him since he had to stop periodically to take a breath. His pulse was high around 120 and his blood pressure was 140/100 which is high. I looked at his skin and there were lesions all over his skin which is Kaposi sarcoma. “Kaposi sarcoma lesions evolve from early (patch stage) macules into plaques (plaque stage) that grow into larger nodules (tumor stage)” (Radu, Pantanowitz, 2013, p. 289).…