Short of breath now after walking 1 flight of stairs or 1 block. Chest tightness. Early morning cough daily, with small amounts of white sputum × 2-3 years. Fatigue and SOB at work. Has 2-pillow, orthopnea at night. Wakes 2-3 times/night to urinate or “catch breath.” States’ thinking of quitting smoking, but previous attempts have not worked. Objective Vital signs: BP 148/88 mm Hg. Temp 98° F (36.7° C). Pulse 88 bpm. Resp 24/min. Weight 134 lbs. Inspection: Sitting on side of bed with arms propped on bedside table. Respirations: resting 24/min, regular, shallow with prolonged expiration; resp. ambulating 34/min. Increased use of accessory muscles, AP = transverse diameter with widening of costal angle, tense expression. Palpation: Minimal but symmetric chest expansion. Tactile fremitus = bilaterally. No lumps, masses, or tenderness to palpation. Percussion: Hyperresonance over lung fields. Auscultation: Breath sounds diminished. Expiratory wheeze throughout posterior chest, R >L. No crackles. WHAT ARE THE NORMAL AND ABNORMAL FINDINGS YOU COULD THINK FROM THE CLIENT'S DATA ANALYSIS ?
Subjective
Short of breath now after walking 1 flight of stairs or 1 block. Chest tightness. Early morning cough daily, with small amounts of white sputum × 2-3 years. Fatigue and SOB at work. Has 2-pillow, orthopnea at night. Wakes 2-3 times/night to urinate or “catch breath.” States’ thinking of quitting smoking, but previous attempts have not worked.
Objective
Vital signs: BP 148/88 mm Hg. Temp 98° F (36.7° C). Pulse 88 bpm. Resp 24/min. Weight 134 lbs.
Inspection: Sitting on side of bed with arms propped on bedside table.
Respirations: resting 24/min, regular, shallow with prolonged expiration; resp. ambulating 34/min. Increased use of accessory muscles, AP = transverse diameter with widening of costal angle, tense expression.
Palpation: Minimal but symmetric chest expansion. Tactile fremitus = bilaterally. No lumps, masses, or tenderness to palpation.
Percussion: Hyperresonance over lung fields.
Auscultation: Breath sounds diminished. Expiratory wheeze throughout posterior chest, R >L. No crackles.
WHAT ARE THE NORMAL AND ABNORMAL FINDINGS YOU COULD THINK FROM THE CLIENT'S DATA ANALYSIS ?
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