I need discussion respond to this posting. Can someone help ASAP
I need discussion respond to this posting. Can someone help ASAP!!
Week 6 Main Discussion Post:Case 3Patient Name:J. H.Age:68Gender:MaleSubjective Data:Chief Complaint (CC):“ I don’t feel good. I’m short of breath and its getting worse.”History of Present Illness (HPI):Mr. Hendrick is a 68-year-old Caucasian male who complains of SOB and fatigue that hasincreased over past couple days. He explains his cough is getting worse; he’s tired all the time and isworried he may have lung cancer. Walking and talking make his SOB worse, and it is impacting hisability to sleep. He has taken Tylenol for his fever and chills, but “nothing is making it better.” Hecomplains of a sharp pain to his right upper chest that is present when he coughs, which isaccompanied by thick, green, blood-tinged sputum. He rates the chest pain a 6/10 during a cough;otherwise, he is pain-free.Medications:Tylenol 1,000 mg as neededAllergies:No known drug, food, or environmental allergies.Past Medical History (PMH):Varicella as a childScarlet fever as childPast Surgical History (PSH):Vasectomy in 2003Sexual/Reproductive History:He is heterosexual with one sexual partner. Denies a history of STIs or problems with hislibido.
Personal/Social History:Patient has smoked for 30 years and has recently cut back to three cigarettes a day. Noalcohol or illicit drugs use.Immunization History:Up-to-date. T-dap in 2010 and Influenza vaccine received in December 2016. Has notreceived the pneumococcal vaccine.Significant Family History:Mother is deceased, age 75, breast cancer.Father is deceased, age 82, complications from myocardial infarction.He has two adult children that are alive and healthy with no significant medical problems.Lifestyle:J. H. has a bachelor’s degree in criminal justice and recently retired from his local policedepartment after 30 years. He plays golf, walks 3 miles each day, and enjoys eating fruits andvegetables from his garden. He lives in a retirement community with his wife and attends churchevery Sunday.Review of Systems (ROS):General:Positive fatigue, fever, and chills. Denies any recent weight gain or weight loss.HEENT:Head: Denies history of head trauma or headaches. Eyes: Patient wearseyeglasses; last eye exam was 6 months ago, no vision changes, floaters, excess tearing, or history ofeye infections. Ears: He denies trauma, tinnitus, or hearing loss. Nose: Positive congestion, deniesdrainage, or changes in his sense of smell. Throat: Denies a sore throat. No problems chewing orswallowing food. His last dental exam was 9 months ago, no issues with dental caries or oral lesions.Neck:Denies pain, swelling, or injury. Full ROM.Breasts:No lumps, drainage, or changes to his breast.Respiratory:Dyspnea with and without excretion that increases when walking and talking.Persistent, moist, productive cough accompanied with thick, green, blood-tinged sputum.
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