Heart & the lungs assessment

Sample Solution

   

Subjective Data

• The patient is a 55-year-old male who presents with a chief complaint of shortness of breath.
• The patient states that he has been experiencing shortness of breath for the past few months. The shortness of breath is worse when he walks up stairs or hills.
• The patient also reports chest pain that is sharp and stabbing. The chest pain is worse when he exerts himself.
• The patient has a history of hypertension and diabetes.

Full Answer Section

      Objective Data

• Vital signs: Temperature 98.6°F, pulse 100 beats per minute, respirations 22 breaths per minute, blood pressure 140/90 mmHg
• General appearance: The patient is a well-developed, well-nourished male in no acute distress.
• Skin: The skin is warm, dry, and pale.
• Neck: The jugular veins are not distended.
• Lungs: The lungs are clear to auscultation bilaterally.
• Heart: The heart rate is regular and there is no murmur.

Assessment The patient is a 55-year-old male with shortness of breath and chest pain. The physical examination is consistent with heart disease. The patient's history of hypertension and diabetes are also risk factors for heart disease. Plan The patient will be referred to a cardiologist for further evaluation. The cardiologist will likely order an electrocardiogram (EKG) and echocardiogram to assess the patient's heart function. Skills Utilized The following skills were utilized during the assessment:

• Inspection: This was used to assess the patient's general appearance, skin color, and neck veins.
• Palpation: This was used to assess the patient's pulse, respirations, and heart rate.
• Auscultation: This was used to assess the patient's lungs and heart.

Summary The patient is a 55-year-old male with shortness of breath and chest pain. The physical examination is consistent with heart disease. The patient's history of hypertension and diabetes are also risk factors for heart disease. The patient will be referred to a cardiologist for further evaluation.