Physical exam vs t 979 rr 32 labored hr 112 bp 14888

Physical exam : VS: T 97.9, RR 32 labored, HR 112, BP 148/88, O2 sat 90%RA, WT 210lbs
GENERAL: Patient is well nourished and appears to be in acute distress and experiencing SOB
CARDIOVASCULAR- Heart rate is irregular with good s1 and s2, no s3 or s4, no murmur,
gallops, or rubs
RESPIRATORY-tachypnea, labored breathing pattern, diminished breath sounds in R middle and
lower lobes, no rales, rhonchi or wheezing
GI- Abd is protuberant with normoactive bowel sounds x 4 quadrants
SKIN- Skin is cool and diaphoretic
PERIPHERAL VASCULAR: R LE + 2 edema, + erythema + pain/ tenderness, + homan’s sign,
LLE without edema/erythema, +2 dorsalis pedis bilaterally
Diagnostic results :
1. EKG-An electrocardiogram records the electrical signals in your heart. It's a common test
used to detect heart problems and monitor the heart's status ("Electrocardiogram (ECG or
EKG)," 2019)
2. Chest x-ray-Chest x-ray uses a very small amount of ionizing radiation to produce
pictures of the structures inside of the chest. It is used to evaluate the lungs, heart and

chest wall and may be used to help diagnose shortness of breath, persistent cough, fever,
chest pain or injury ("Chest X-ray (Radiograph)," n.d.).
3. VQ SCAN- A ventilation–perfusion (VQ) scan is a nuclear medicine scan that uses
radioactive material to examine airflow and blood flow in the lungs, its great at detecting
PE in the lungs.