CC: “I can hardly breathe; the correct facet of my chest is extremely tight and uncomfortable.”
•HPI:
Age: fifty years
Intercourse: Male
Histories of submitting complaints:
Mr. XY, a fifty-year-old man, seems to the establishment with a three-day historical past of chest pains and sudden onset of shortness of breath. He studies that the left facet of his chest is excruciatingly uncomfortable and charges the discomfort as a 9 out of 10. She described his struggling because the worst he has ever skilled. Every week earlier, he had related chest issues, however he went to a neighborhood medical establishment the place he was recognized with pneumonia. He was given Amoxicillin and Zithromax, and he has been taking them. He studies compliance and a modest enchancment whereas utilizing these medicines. Nonetheless, the discomfort endured and the shortness of breath worsened all through the final twenty-four hours. The discomfort is situated under the axilla, close to the center of the ribcage. Each coughing and little motion exacerbate it. He mentions a sound emanating from the thoracic cavities. He denies having a fever, chills, vomiting, diarrhea, or cough. The minor swelling of his decrease leg is indicative of deep vein thrombosis.
Evaluation of Programs
Constitutional: Reviews no weight change, night time sweats, or weariness over time.
Respiratory: He’s tachypneic and his respiration is tough.
•Medical Historical past: His mom had hypertension. •Surgical Historical past: He has a historical past of appendicectomy. •Household Historical past: He’s divorced and lives alone. Nonetheless, his prolonged household is accommodating, they usually get alongside quick.
Ten years in the past, he smoked a minimum of half a pack of cigarettes each day. A pair bottles of wine are consumed by him socially in the course of the weekend. He’s lively bodily.
He has no recognized meals, medicine, or environmental sensitivities.
•Drugs: Present therapy for pneumonia consists of Amoxicillin and Zithromax
Very important indicators
Temperature – 37℃
108 beats per minute is the guts price.
Fee of Respiration: 32 beats per minute
Strain of Blood: 128/73 mmHg
Oxygen 90% saturation
Medical Examination
Basic: An apprehensive 50-year-old man laying on the examination mattress appears distressed and speaks with appreciable reluctance.
Imaginative and prescient is unbroken, a minor nasal discharge is obvious, and a headache is prevalent.
Cardiac: left facet ache current, no palpitations, no peripheral limb edema, no coronary heart murmurs, and no rubs.
Lungs: widespread crackles current, now wheezes evident, bilaterally lowered airflow
Absence of abdomen distension, presence of regular bowel sounds, and absence of organomegaly
No peripheral cyanosis, no finger clubbing, and capillary refill time of lower than three seconds.
Neurological: Affected person is totally conscious of the time, location, and identification
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