Question

Using the information answer the following questions from this case study scenario, A 50 year old...

Using the information answer the following questions from this case study scenario,

A 50 year old African American male present in the Emergency room with complaints of severe shortness of breath, fatigue over several days. Patient states a weight gain of over 10 lbs. in a week and his shoes not fitting. He states that he gets up in the middle of the night due to inability to breath. No history of smoking, but patient states he is a diabetic and has hypertension.

Physical examination: BP 150/85, R 24, HR 96, T 98.6, & BG 180. Increased shortness of breath when asked  to  lie down requiring elevation  of  exam table.   Patient  ambulates  with difficulty  and slowly.

Productive cough- pink tinge, frothy sputum. Breath sounds- diminished bilateral bases with crackles throughout upper lung fields. JVD present.  Pedal edema+ 3.

  1. List Normal Subjective findings: (1 pts)
  1. List Abnormal Subjective findings:  (1  pts)
  1. List Normal Objective findings: (1 pts)
  1. List Abnormal findings:  (1 pts)
  1. Identify the pathology and what are the disease processes and the sequence of events (what caused what). (2 pts)
  1. List what health history questions and physical  assessment  you would perform.  You must be specific.  No lab, EKG, etc.  (4 pts)
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Answer #1

Normal subjective finding is no history of smoking.

Abnormal subjective finding iscomplaints of severe shortness of breath, fatigue over several days. Patient states a weight gain of over 10 lbs. in a week and his shoes not fitting. He states that he gets up in the middle of the night due to inability to breath. patient states he is a diabetic and has hypertension.

Normal objective findings are R 24, HR 96, T 98.6,

Abnormal findings are: BP 150/85 & BG 180. Increased shortness of breath when asked  to  lie down requiring elevation  of examination table.   Patient  ambulates  with difficulty  and slowly.

Productive cough- pink tinge, frothy sputum. Breath sounds- diminished bilateral bases with crackles throughout upper lung fields. JVD present.  Pedal edema+ 3.

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