Will Emerson pt
O2 – 92% on 2L
HR – 110
Temp- 103 oral
Pain – 4/10; Located all over; chest and back area mainly, feels like an elephant is sitting on him. Nothing relieve the pain. No pain meds taken. Allergic to penicillin and morphine sulfate. Takes Xopenex daily. Not feeling lightheaded or dizzy, feels ok while sitting, doesn’t want to walk anywhere. Fall risk.
General appearance – anxious and unkept, breathing at 34bpm, disheveled, weak and tired.
Skin – pale, hot, clammy, diaphoretic. Clubbing noted, cap refill <3 secs, 1+ pitting edema lower extremities.
Heart – 110 tachy, S1S2 heard in all points, no mummers present, radial, dorsalis pedis, posterior tibialis pulses are weak bilaterally 1+. Carotid 3+. 1+ edema in lower extremities.
2nd intercoastal right of sternal boarder aortic
2nd intercoastal space left of boarder pulmonic
3rd intercoastal space left of boarder Erb’s point
4th intercoastal space
History of COPD, use of assessor muscles, SOB, on O2 @ 2L pm
Anterior lung sounds; RUL, LUL, RML, LLL, RLL
posterior – RUL, LUL, LLL, RLL, LLL, RLL
Adventitious rhonchi sounds heard in all fields, barrel chested in appearance, pt shows signs of acute distress.
GI- weighs 70kg, and 175cm tall and belly is rounded soft and no pain on palpation, hyperactive bowel sounds heard in all quadrants.
GU – voiding dark yellow urine
Extremities – generalized weakness, not out of bed
Skin – no rashes, clubbing present and cap refill less than 3 seconds, pale, skin is hot and diaphoretic.
Neuro – alert and oriented x 4, pupils, equal, round, reactive to light and accommodation, EOM’s are intact, behavior is anxious, speech is clear and coherent.
Lymph nodes – Lymph nodes are enlarged and tender.