NRNP 6550 Week 5 i-Human Case Study Alvin Stafford
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NRNP6550wk5ihuman Alvin Stafford 63y.o.
5’11 142lbs 64.0kg
short of breath for two days worsening dypnea with exertion
productive cough with yellow-green sputum medical history of COPD
smoking 2 since 16 years old drink beer per day
loss of appetite wheezing runny nose BLE swelling
Wife deceased, lives alone palpitation
NKA
Physical exam:
T: 99.5
P 98
R 32
BP 152/92 SPO2 91%
SPCO2 6%
eTCO2 45mmhg clubbing
barrel chest
<2cm diaphragmatic excursion use of accessory muscle exertion thorax hyperresonant
exp wheezing
PMI displaced to subxiphoid area Decreased activity tolerance
HPI:
The patient is a 63-year-old male presenting with increased dyspnea upon exertion for 2 days associated with worsening cough producing increased yellow-greenish sputum. The patient is a chronic 94 pack-year cigarette smoker who was diagnosed with COPD and is noncompliant with his prescribed medications. Associated symptoms reported include decreased exercise tolerance due to dyspnea, palpitation upon exertion and decreased appetite. Physical exam revealed tachypnea, bilateral expiratory wheezes, decreased diaphragmatic excursion with barrel chest, displacement of the PMI, low grade fever and mild diffuse clubbing. Besides associated clinical findings, his BP was noted with elevated at 152/90 without prior history of hypertension……….. Continue
