NUR-643E Health Assessment Check-Off Project Paper

NUR-643E Health Assessment Check-Off Project Paper

NUR-643E Health Assessment Check-Off Project Paper

Physical Exam Documentation
Chief Complaint: Shortness of breath and chest tightness.
History of Present Illness:
A.L. is a 75-year-old A. A male with a chief complaint of shortness of breath (SOB) and chest tightness. The symptoms began ten weeks ago during the fall and have worsened over time to a point where the SOB and chest tightness impair his daily activities. Besides, the SOB has interfered with eating resulting in significant weight loss. He reports having a prolonged cough with colorless sputum production in the past 15 months. He has repeatedly been to the community clinic and administered cough suppressants and antibiotics for the cough and sputum, but they only offered temporary relief. He reports that the symptoms have significantly affected his daily activities, including his work at his farm.

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Past Medical History (Hx):
No history of chronic illnesses. He has been diagnosed thrice with Community-acquired pneumonia in the past two years.
Past Surgical Hx:
Hemorrhoidectomy at 47 years.
Family Hx:
The father had Diabetes and died from renal failure at 89 years. The mother died from stroke at 84 years. His paternal grandmother had Alzheimer’s disease. The elder sister has Diabetes. Children are alive and healthy.
Social Hx: The patient is a retired civil servant. He is married and has four children aged 44, 41, 37, and 31. He lives with his wife on his rural farm. He has a history of alcohol consumption for 45 years and tobacco smoking for 40 years 2PPD. He quit smoking three months ago when the community nurse advised him to quit due to the prolonged cough. His hobbies include watching soccer and reading magazines.
Allergies: No food, drug, or seasonal allergies.
Medications: Cough suppressant.
Review of Symptoms by System:
General: Reports weight loss and reduced energy levels. Denies fever.
Cardiovascular: Reports SOB and chest tightness. Denies palpitations or edema.
Pulmonary: Reports SOB, cough, sputum production, chest tightness, and wheezing
Physical Exam:
Vital signs: HR-104; BP- 136/84; RR-28; Temp- 98.42 F; Sp02-88.
Height- 5’3; Weight- 119; BMI- 21.1
General: Elderly AA male patient in mild respiratory distress. He is well-groomed and appropriately dressed for the function and weather. Maintains eye contact; speech is clear and coherent.
Respiratory: Barrel chest. Use of pursed-lip breathing and accessory respiratory muscles. Prolonged expiration. Bilateral wheezes on forced and unforced expiration. Diffusely decreased breath sounds bilaterally. Hyperresonance on percussion
Cardiovascular: No edema or distention of neck veins. Distant heart sounds. No gallop sounds or murmurs.
Assessment Steps:
The patient’s symptoms suggested a restrictive respiratory disease, Asthma or COPD. To differentiate the two, the clinician performed pulmonary function testing before and after administering Albuterol (Ballas, 2018).
Before administering Albuterol: FEV1- 50%; FEV1/FVC- 60%; After administering Albuterol: FEV1- 50%; FEV1/FVC- 60%.
The patient’s FEV1/FVC did not improve with Albuterol therapy which ruled out Asthma as the primary diagnosis (Ballas, 2018). An FEV1/FVC of 60% that did not improve with Albuterol indicated COPD.
Treatment Plan:
Medication: Nebulization with Albuterol 2.5 mg every 2 hours to promote bronchodilation.
Albuterol 2 to 4 puffs (100 mcg/puff) by metered-dose inhaler for acute exacerbations. Inhalation using a metered-dose inhaler causes rapid bronchodilation (Bollmeier & Hartmann, 2020).
Prednisone 40 mg orally OD for 5 days. The dose will be tapered over 7 days, depending on the patient’s clinical response. This is an anti-inflammatory agent. It is recommended in treating acute COPD exacerbations to prevent inflammation that causes exacerbations (Bollmeier & Hartmann, 2020).
Non-pharmacological: Oxygen therapy with humidified oxygen via a mask.
Patient Education: The patient was educated to avoid smoke and environmental pollutants. He was advised to engage in moderate physical exercises to improve respiratory functioning and reduce COPD exacerbations. Medication compliance was emphasized to prevent COPD exacerbations (Bollmeier & Hartmann, 2020).
Follow Up: Follow up after one week to assess response to treatment.  
Ballas, Z. K. (2018). Asthma clinical practice guidelines: Time for an update. Journal of Allergy and Clinical Immunology, 142(3), 787.
Bollmeier, S. G., & Hartmann, A. P. (2020). Management of chronic obstructive pulmonary disease: A review focusing on exacerbations. American Journal of Health-System Pharmacy: AJHP: Official journal of the American Society of Health-System Pharmacists, 77(4), 259–268.


Complete the “NUR-643E Health Assessment Check-Off Project” template using a patient with whom you have previously worked. Ensure that you have adequately completed the assessment steps and given a proper recommendation.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines

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