Module 08 Lab Assignment – Documentation a Respiratory Examination
Module 08 Lab Assignment – Documentation a Respiratory Examination
Neurologic System Patient Case
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Subjective data
Mr. Green is a 52-years-old, visiting the office today. He’s currently experiencing headaches and blurry vision. Mr. Green has a history of stroke and hypertension. He was previously admissions for blood transfusion, and history of surgeries. He is allergic to aspirin
Palliation– Mr. Green reports, wearing his glasses help him see better.
Quality- The pain is throbbing and pounding
Region of the pain– Pain is located in his eye.
Severity-He describes the severity of (10/ 10)
Timing– present for the last few hours.
Understanding and impact– he reported unhappy due to the pain and blurred vision affect his daily living and life activities.
Objective data
The vital signs of Mr. Green include Temperature-36.8 C, HR- 88BPM, respiratory rate- 22BPM, and BP- 168/92 mmHg. The patient is alert but confused and oriented only to person and place and not oriented to time. He has a slurred speech.
Mr. Green, cranial nerves II and VII are impaired. Others cranial nerves are intact.
Upon examining his motor skills, Mr. Green’s muscle strength in the left arm is 2/ 5 while the left leg is 3/ 5. Sensory examination to assess the sensations, including temperature, vibration, pain, and proprioception are intact.
Actual and potential risks.
Mr. Green has blurred vision because the assessment findings indicate that the cranial nerve II (optic nerve) is impaired. The stroke might have affected the parts of the brain which control the optic nerve and therefore causing damage to the muscles. He also has hemiplegic headaches, which are throbbing, severe, and are accompanied by confusion.
Mr. Green is at risk of facial nerve paralysis because the assessment findings indicate that the cranial nerve VII (Facial nerve) is impaired, and the patient has left lower facial droop. It can affect the ability to blink a smile and difficulty in making various facial movements (Hinkle & Cheever, 2018). It can result when any part of the facial nerve muscles is either damaged or inflamed.
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PatientcaseforModule-8RespiratoryPatient.docxRespiratory 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 and answer 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…..