NR 603 Week 4 iHuman Case; Constance Barn, 70 yrs old, dsypnea
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$20.00
| Institution | Chamberlain |
| Contributor | Hartnett Kara |
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Physical exam: 70%
***IF YOU GO DOWN THE PE LIST AND DO THEM ALL, IT WILL GIVE YOU A 90+% SCORE
1 Temperature: 96.8F, 36.0C 2 Oxygen: SpO2: 97%
- Respiration-14, regular, unlabored
- Bp- 146/88 left arm and right arm, normal pulse pressure, elevated **** I think it needs to be all arms and orthostatic BP too
· I got 144/88 standing/orthostatic in both arms 5 Pulse- 88 bpm, regular, normal
- Inspect skin all over: Skin warm and dry, no lesions seen
Inspect hair color, distribution, thickness: thickness and distribution pattern typical for patient gend
- Inspect nails: Nails without ridging, pitting or peeling 8 Test cap refill: Normal capillary refill
- Inspect eyes: Eyelids; no ptosis erythema or swelling, conjunctivae: pink, no discharge, sclerae: anicteric, orbital area: no edema, redness, tenderness or lesion noted
- Inspect ears: Normal appearing external structures, no deformities or edema, no discharge noted
Otoscope findings: External auditory canals without erythema or cerumen, tympanic membranes translucent, non-injected & pinkish-gray in color; no scarring, discharge, or purulence noted; landmarks visible.
- Ophthalmoscope: red reflex bilaterally, optic disks sharp
- Inspect nose: No discharge or polyps, no edema or tenderness over the frontal or maxillary sinuses
- Look up nostrils: No polyps or discharge
- Inspect mouth /pharynx: Oropharynx not injected, clear mucosa, tonsils without exudate, tongue pink, symmetrical, no swelling or ulcerations
- Inspect neck: No visible scars, deformities or other lesions, trachea is midline and freely mobile, no asymmetry or accessory respiratory muscle use with quiet breathing.
Ask patient to swallow: Normal exam; thyroid moves with swallowing 16 JVP: Normal jugular venous pressure (JVP)
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| Instituition / Term | |
| Term | Nursing |
| Institution | Chamberlain |
| Contributor | Hartnett Kara |
