Patricia Newman, 61 admitted with dyspnea at rest, cough, and fever Smoker x 45 years; 2ppd
Multiple hospitalizations for pneumonia in past 2 years Osteoporosis x 8 years
HTN x 15 years
Divorced x 15 years; 2 adult ch
...
Patricia Newman, 61 admitted with dyspnea at rest, cough, and fever Smoker x 45 years; 2ppd
Multiple hospitalizations for pneumonia in past 2 years Osteoporosis x 8 years
HTN x 15 years
Divorced x 15 years; 2 adult children live out of state Mother d at 63 of MI; father d at 59 of stroke
Medications at Home:
Calcium carbonate 600 mg 4 times per day Estrogen patch twice a week Chlorothiazide 500 mg daily
Atenolol 50 mg daily
Sleeps on 2 pillows at night Emphysema for 12 years
Frequent cough productive of moderate amount of yellow sputum Short of breath when walking 20 feet
HTN well controlled on meds; no other known cardiovascular problem
Objective:
T – 101.1; B/P – 162/90; R – 26, regular, slightly labored; P – 108, regular O2 sat 89% on room air
Lungs – coarse crackles throughout lungs; using accessory muscles to breathe Mental status – alert oriented to person, place, time; cranial nerves intact; PERRLA Abomen flat, nontender; bowel sounds active; pulse 2+ all extremities
Q1 Which of the clinical manifestations are abnormal and why? What would normal findings be?
High temperature, high pulse, high respirations, low O2 saturations, crackles are also abnormal, accessory muscles, labored reparations because they are all out of normal ranges, some of the normal findings would be a 2+ pulse, flat nontender abdomen, and active bowel sounds. Normal vital signs, being able to walk 20 feet
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