CV: + sharp, constant chest pain, increase with inspiration. Palpitations. Right leg edema. 2+ pedal pulses. No murmur. Irregular heart rhythm. GI: no nausea or vomiting. Abdomen has normal bowel sounds. GU: No problem with urinary pattern or incontinence. MS: no limitation or problem with muscular
Psych: No report of SI/HI. Neuro: A+ox4. Denies dizziness, or headaches, No recurrent falls. Integument/Heme/Lymph: erythema, warm to touch and tenderness to right calf. Endocrine: No endocrine symptoms Allergic: No symptoms Objective: Physical Exam: Vitals signs: B/P 148/88, P112, R 32 labored, T 97.9, O2 90%. WT: 210 Ibs, A+Ox4, diminished lung sounds to right mid and lower lobe, irregular heart rate, anxious, Skin cool and diaphoretic. Right calf erythema, edema, and warm to touch with +2 pedal pulses. Assessment: Based on Mr H physical exam along with lab results, ECG, chest X-ray, venous Doppler of the right calf, which would reveal a Deep Vein Thrombosis (DVT) which can lead to a pulmonary emboli (PE). The diminished lung sounds heard over the right and mid lobe can reveal a PE in the right lung. Differential Diagnoses: 1. Pulmonary Embolism (PE) is a sudden onset of severe, sharp, crushing, non-radiating chest pain if there is an embolus impacting an artery (Dains, Baumann, and Scheibel, 2016). Infarction of the pulmonary parenchyma closer to the pleural surface can cause pleuritic chest pain, with sudden dyspnea and hemoptysis with restlessness, tachycardia,
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- Summer '15
- chest pain, pleuritic chest pain