Module 08 Lab Assignment – Documentation A Respiratory Examination

Respiratory 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…..