JOSEPH CAMELLA "SHORTNESS OF BREATH” IHUMAN CASE STUDY 2024 EDITION | FULLY SOLVED, Exams of Nursing

Download JOSEPH CAMELLA "SHORTNESS OF BREATH” IHUMAN CASE STUDY 2024 EDITION | FULLY SOLVED and more Exams Nursing in PDF only on Docsity! JOSEPH CAMELLA "SHORTNESS OF BREATH” IHUMAN CASE STUDY 2024 EDITION | FULLY SOLVED (PROFESSOR VERIFIED) | ALREADY GRADED A+ JOSEPH CAMELLA "SHORTNESS OF BREATH" 65 Years old male patient came to the clinic with the complaint of: • Chief complaints: Shortness of breath, • HPI: 65 years old male presents with acute on chronic shortness of breath. Patient endorses 1.5 weeks of shortness of breath. Other associated symptoms include chronic productive sputum (yellow), chills, nausea, upper abdominal pain related to coughing, chest pain with coughing. Denies emesis, diarrhea, headache, dysphagia, myalgia  Eyes: Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. EOM are intact, PERRLA. Fundi appear normal including optic discs and vessels. No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions.  Ears: The external ear and ear canal are non-tender and without swelling. The canal is clear without discharge. The tympanic membrane is normal in appearance with normal landmarks and cone of light. Hearing is intact with good acuity to whispered voice.  Nose: Nasal mucosa is pink and moist. The nasal septum is midline. Nares are patent bilaterally.  Throat: Oral mucosa is pink and moist with good dentition. Tongue normal in appearance without lesions and with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is normal in appearance without tonsillar swelling or exudates.  Neck: The neck is supple without adenopathy. Trachea is midline. Thyroid gland is normal without masses. Carotid pulse 2+ bilaterally without bruit. No JVD.  Cardiac: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity.  Respiratory: Expiratory wheezes heard throughout; Crackles noted in RLL Increased respiratory effort  Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted.  Genital/Rectal: Normal rectal sphincter tone. No external masses or lesions. Stool is normal in appearance. guac negative.  Spine: Neck and back are without deformity, external skin changes, or signs of trauma. Curvature of the cervical, thoracic, and lumbar spine are within normal limits. Bony features of the shoulders and hips are of equal height bilaterally. Posture is upright, gait is smooth, steady, and within normal limits.  No tenderness noted on palpation of the spinous processes. Spinous processes are midline. Cervical, thoracic, and lumbar paraspinal muscles are not tender and are without spasm.  No discomfort is noted with flexion, extension, and side-to-side rotation of the cervical spine, full range of motion is noted. Full range of motion including flexion, extension, and side-to-side rotation of the thoracic and lumbar spine are noted and without discomfort.  Straight leg raise test is negative bilaterally. Sensation to the upper and lower extremities is normal bilaterally. No clonus is noted. Grip strength is normal bilaterally. Dorsi/plantar flexion is normal bilaterally.  Extremities: Upper and lower extremities are atraumatic in appearance without tenderness or deformity. No swelling or erythema. Full range of motion is noted to all joints. Muscle strength is 5/5 bilaterally. Tendon function is normal. Capillary refill is less than 3 seconds in all extremities. Pulses palpable. Steady gait noted.  Neurological: The patient is awake, alert and oriented to person, place, and time with normal speech. Motor function is normal with muscle strength 5/5 bilaterally to upper and lower extremities. Sensation is intact bilaterally. Reflexes 2+ bilaterally. Cranial nerves are intact. Cerebellar function is intact. Memory is normal and thought process is intact. No gait abnormalities are appreciated.  Psychiatric: Appropriate mood and affect. Good judgement and insight. No visual or auditory hallucinations. No suicidal or homicidal ideation.