Adventitious rhonchi sounds heard in all fields, barrel chested in appearance, pt shows signs of acute distress

Will Emerson pt

Empressed

 

BP-156/60

O2 – 92% on 2L

RR- 34

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.

2^nd intercoastal right of sternal boarder aortic

2^nd intercoastal space left of boarder pulmonic

3^rd intercoastal space left of boarder Erb’s point

4^th intercoastal space

Respiratory –

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.