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NR 507 Week 3 Case Study- Pulmonary Disease
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- Chamberlain College Of Nursing
Chamberlain NR 507 Week 3 Case Study- Pulmonary Disease
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Week 3 Case Study – Pulmonary DiseaseChief Complaint
A.C., is a 61-year old male with complaints of shortness of breath.
History of Present Illness
A.C. was seen in the emergency room 1 week ago for an acute onset of mid-sternal
chest pain. The event was preceded with complaints of fatigue and increasing
dyspnea for 3 months, for which he did not seek care. He was evaluated by
cardiology and underwent a successful and uneventful angioplasty prior to
discharge. Despite the intervention, the shortness of breath has not improved. Since
starting cardiac rehabilitation, he feels that his breathlessness is worse. The
cardiologist has requested that you, his primary care provider, evaluate him for
further work-up. Prior to today, his last visit with your practice was 3 years ago
when he was seen for acute bronchitis and smoking cessation counseling.
Past Medical History
Hypertension
Hyperlipidemia
Atherosclerotic coronary artery disease
Smoker
Family History
Father deceased of acute coronary syndrome at age 65
Mother deceased of breast cancer at age 58.
One sister, alive, who is a 5 year breast cancer survivor.
One son and one daughter with no significant medical history.
Social History
35 pack-year smoking history; he has cut down to one cigarette at bedtime
following his cardiac intervention.
Denies alcohol or recreational drug use
Real estate agent
Allergies
No Known Drug Allergies
Medications
Rosuvastatin 20 mg once daily by mouth
Carvedilol 25 mg twice daily by mouth
Hydrochlorothiazide 12.5 mg once daily by mouth
Aspirin 81mg daily by mouth
, Week 3 Case Study – Pulmonary Disease
Review of Systems
Constitutional: Denies fever, chills or weight loss. + Fatigue.
HEENT: Denies nasal congestion, rhinorrhea or sore throat.
Chest: + dyspnea with exertion. Denies productive cough or wheezing. + Dry,
nonproductive cough in the AM.
Heart: Denies chest pain, chest pressure or palpitations.
Lymph: Denies lymph node swelling.
General Physical Exam
Constitutional: Alert and oriented male in no apparent distress.
Vital Signs: BP-120/84, T-97.9 F, P-62, RR-22, SaO2: 93%
Wt. 180 lbs., Ht. 5'9"
HEENT
Eyes: Pupils equal, round and reactive to light and accommodation, normal
conjunctiva.
Ears: Tympanic membranes intact.
Nose: Bilateral nasal turbinates without redness or swelling. Nares patent.
Mouth: Oropharynx clear. No mouth lesions. Dentures well-fitting. Oral
mucous membranes dry.
Neck/Lymph Nodes
Neck supple without JVD.
No lymphadenopathy, masses or carotid bruits.
Lungs
Bilateral breath sounds clear throughout lung fields. + Bilaterally wheezes
noted with forced exhalation along with a prolonged expiratory phase. No
intercostal retractions.
Heart
S1 and S2 regular rate and rhythm, no rubs or murmurs.
Integumentary System
Skin cool, pale and dry. Nail beds pink without clubbing.
Chest X-Ray Forced Expiration
Lungs are hyper-inflated bilaterally with a flattened diaphragm. No effusions
or infiltrates.
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