Question

Resp Pt The patient is a 60-year-old white female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain, abdominal distension, nausea, vomiting, and diarrhea. She does report difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled requiring blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower extremities that is new onset and worsening. Subsequently, she has not ambulated from bed for several days except to use the restroom due to feeling weak, fatigued, and short of breath. quency, indy, she has a short of bir There are no known ill contacts at home. Her family history includes significant heart disease and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years. She quit smoking 2 years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known foods, drugs, or environmental allergies. Vitals HR 90, B/P 147/68, 02 90% on RA, RR 19,98.7 Oral temp

Document the information in objective and subjective data and abnormalities. It is respiratory documentation.

Physical assessment

Answer 1

A 60-year-old white female presented in an emergency with acute onset of Shortness of breath.

Subjective data-

- Dyspnoea at rest

- Forgetfulness

- Weakness and Fatigue

- Chills

- Increase urine frequency

Objective data-

- Dyspnoea

- Bilateral edema at lower extremities

- Incontinence