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Health assessment

Pulmonary System
Subjective
1. Chief complaint
a. “I can’t breathe!”
2. History of present illness
a. Mrs. K. is a 65 year old white female who presents to the office with a
complaint of progressive onset of difficulty breathing. She has noticed a
decrease in the amount of activity she can do before symptoms begin.
Thinking it was just a cold, she did not seek treatment for some time.
Symptoms began roughly 6 months ago and have progressively worsened to
where she is unable to do simple activities of daily life without having to stop
and catch her breath.
3. Past medical history
a. MI in 2004, stents x 3
b. Gerd
c. Sleep apnea
d. Hypertension diagnosed 6 years ago
e. Hysterectomy at the age of 26
f. No childhood history of breathing issues
4. Family history
a. Father died of cancer at age 73
b. Mother has no significant health history
c. Husband is a farmer
d. Has 2 grown children
5. Social history
a. Works on the farm with her husband and 2 children tending to cows, chickens
and horses.
b. Current smoker – 1ppd since age 26
6. Review of systems
a. General
i. Has some increased work of breathing at rest. Feels like she can’t get air
out. Does not appear distressed or anxiousness at this time.
ii. Gets tired and short of breath with small activities such as walking up the
stairs and getting the mail. Has a harder time breathing with physical
tasks such as feeding the farm animals.
b. Skin
i. Denies pain or tenderness of skin
ii. Afebrile.
iii. Denies bruising or discoloration of skin.
c. Eyes:
i. Denies changes in vision.
ii. Wears bifocals for reading.
d. Ears
i. Denies changes in hearing.
ii. Denies vertigo or tinnitus.
e. Nose/mouth/throat
i. Denies nasal congestion and nasal discharge.
ii. Denies difficulty with swallowing.
f. CV
i. Denies chest pain or heart palpitations.
ii. History of heart attack in 2004, had 3 stents placed.
iii. Has seen cardiologist as scheduled. Takes antihypertensive pills daily.
iv. Unable to remember names and doses.
g. Respiratory
i. Has been coughing up moderate amounts of mucous. Has been doing this
for roughly 1 month.
ii. States it is green in color.
iii. Denies shortness of breath or cough.
iv. Room air saturation noted at 88% room air. 2 liters NC applied. Pt now
reading 93%.
h. Genitourinary/Gyn (Defer)
i. Will never assess this area.
i. Musculoskeletal
i. Denies any muscle or joint pain.
j. Breast (Defer)
i. Will never assess this area.
k. Neurological
i. Has been more tired lately.
ii. Feels a little stressed because she can’t get the work done that she needs
to.
iii. Denies syncope or vertigo.

Objective
1. Hair
a. No hair loss, loose flakes of skin, or dandruff are seen.
2. Scalp
a. No loose skin or lesions seen, no lumps upon palpation.
3. Skull
a. Normocephalic, no tenderness, depressions, or lumps felt upon palpation.
4. Eyes
a. Denies double vision or blindness.
b. Uses bifocals to read.
5. Ears
a. Eardrum visualized.
b. Cerumen present, no abnormal discharge noted.
6. Nose
a. No discharge or abnormalities seen.
b. No congestion noted.
c. No pain or tenderness upon gentle palpation with the thumbs of the frontal and
maxillary sinuses.
7. Mouth
a. Mucous membranes moist and pink.
b. All teeth intact, no dentures or bridges.
c. Tongue is pink and moist. No evidence of thrush, lesions, or nodules.
d. Class II Mallampati score. Uvula only partially visible, patient able to open mouth
without discomfort.
8. Throat/Neck
a. Thyroid gland normal.
b. Denies difficulty swallowing.
c. No wheezing or stridor noted with breathing.
d. Carotids negative for bruit, pulses palpable.
e. No signs of JVD noted.
f. Patient unable rest supine due to orthopnea.
g. Thyromental distance of 6 cm.
9. Chest/Back/Lungs
a. No signs of anterior or posterior bruising noted.
b. She is short of breath.
c. Confirms cough with green mucous x 1 month.
d. Barrel chest appearance of upper thorax.
e. Upper lobes are positive for expiratory wheeze
f. Positive for egophony which indicates consolidation. Patient says the letter E
while listening over the area of consolidation and resonates as the letter A.
g. Dullness with percussion may indicate secretions or other airway obstruction
from inflammation or fluid. Most prominent posteriorly in the bases of the lungs.
h. The pulmonic area was assessed for pulmonary hypertension by palpating over
the 2nd intercostal space and left of the sternal border. No prominent pulsation
noted as patient held breath during examination.
i. Chest expansion equal bilaterally
j. Negative for scoliosis/kyphosis
10. Heart
a. Normal S1, S2 heard on auscultation
b. No adventitious heart sounds or murmurs noted when stethoscope placed over
the second intercostal space and just to the right of the sternum over the aortic
valve, left of the sternum for the pulmonic valve, lower left of the sternum for
the tricuspid valve, and around to the apex of the heart for the mitral valve.
11. Abdomen
a. No signs of bruising
b. Bowel sounds active in all quadrants
c. Absent for bruit
d. No tenderness upon palpation, no evidence of masses or nodules
e. No abnormalities noted upon palpation of liver and spleen
12. Upper Extremities
a. Normal range of motion bilaterally
b. No tenderness or pain in joints
c. Equal strength bilaterally
d. Warm skin temp, and pulses equal bilaterally
e. No edema noted
f. CRT >3 sec
g. Cyanosis and slight clubbing of nail beds are seen
13. Lower extremities
a. Normal range of motion bilaterally
b. No tenderness or pain in joints
c. Equal strength bilaterally
d. Color, temp, and pulses equal bilaterally
e. CRT > 3 sec
f. Positive for cyanosis on nail beds
Assessment
1. New diagnosis
a. Progressive onset of pulmonary emphysema as manifested by shortness of
breath with exertion, dyspnea at rest, nail bed cyanosis, and clubbing of the
fingernails. Other indications for emphysema are barrel chest and long history of
1 ppd smoker.
2. Further testing
a. CBC, CMP, BNP,
b. EKG, echocardiogram.
c. Chest x-ray – will show dark edges of hyperinflation if positive for emphysema.
d. Sputum culture if able to obtain.
3. Problem list
i. Shortness of breath
1. Applied oxygen for low O2 sat early in the assessment.
2. Will require home O2 if unable to maintain room air saturation of
92%.
ii. Activity intolerance
1. Activity as tolerated
iii. Smoker
1. Must quit smoking
1. Information to patient
a. I have discussed with the patient in detail about my concern for pulmonary
emphysema and the treatment involved. We have discussed the signs,
symptoms and potential complications with and without treating emphysema
such as worsening oxygenation issues, difficulty breathing will get worse with
time, hypoxia, increased heart strain, and possible death.
b. Treatment
i. STOP SMOKING
ii. Acute or long term bronchodilators
iii. Steroids
iv. Antibiotics if lungs are infected
v. Mucolytics
vi. Home oxygen if needed
vii. Arrange a treatment team to help her quit smoking if she is open to the
idea of receiving help.
2. Patient understanding
a. Patient able to verbalize understanding. Able to explain tests and medications
which will be done for treatment. Understands that she may require home
oxygen to help with her oxygenation issues if room air saturations do not
improve with bronchodilators and steroids. States that she understands her
need to quit smoking. Has tried to quit several times but keeps going back.
3. Written/verbal instructions
a. Patient was given teaching packet for smoking cessation and management of
Pulmonary emphysema. Additional information was given to help reinforce
knowledge deficit for signs and symptoms of emphysema and when she should
seek help. Explained to the patient that emphysema is a permanent condition
but can be managed to help her continue managing the farm.
4. Differential diagnosis
a. Emphysema
i. The patient above presented with a progressive onset of shortness of
breath with exertion when working on the farm. Asthma was ruled out
due to the onset process. Asthma typically has a rapid onset. The patient
also had a long-standing history of smoking which also leads us to this
diagnosis as the shortness of breath is not being caused by an allergen.
Clubbing of the fingernails and barrel chest are also very telling signs of
emphysema.
b. Asthma
i. Patients with asthma typically have a more rapid onset of shortness of
breath. This is usually caused by an exposure to some type of allergen
that reacts with the airway and causes the bronchioles to become
inflamed. Wheezing is usually present and rescue inhalers are needed
immediately for severe cases of asthma. Asthma usually presents itself in
young children and symptoms can come and go. Emphysema is caused by
long term damage to the lung tissue and is a permanent condition.
5. Anesthesia specific assessment
a. Lungs
i. Any depression of the respiratory drive for someone with emphysema
puts them at risk for hypoxia and complications associated with it. Mrs. K.
also has a possible lung infection by reporting coughing up green sputum
for a month.
b. Heart
i. With a previous history of an MI and currently taking antihypertensive
medications of unknown name and dose is a huge red flag. Along with
her risks of respiratory compromise, any problems associated with
fluctuations in blood pressure and oxygenation may cause further
myocardial ischemia and tissue damage. Medications should be known
along with the dose.
c. Long term hospitalization
i. With her current lung issues of possible infection, hypoxemia, shortness
of breath and smoking history Mrs. K. has a very high likelihood of long
term hospitalization. She may even require long term ventilator support.
Worst case scenario would be inability to oxygenate without the
ventilator. Another factor that could cause long term hospitalization is a
stroke. Her respiratory status and her heart history increase her chances
for intraoperative stroke.