ABD Soft non tender non distended Bowel sounds present and normoactive in all

Abd soft non tender non distended bowel sounds

This preview shows page 4 - 7 out of 8 pages.

ABD: Soft, non-tender, non-distended. Bowel sounds present and normoactive in all four quadrants. Genital/Rectal: continent of bladder and bowel. No Foley catheter. Musculoskeletal: 5/10 pain on the RLE calf. +2 edema on RLE. Normal range of motion. Normal muscle mass for age. No joint deformities. Neuro: Alert and oriented x4. Strength and sensation intact. No balance deficit. Skin/Lymph Nodes: No cervical lymphadenopathy. No rashes. Warm erythema with +2 edema on RLE. Diagnostic results: Laboratory studies: CBC – WBC 7.9; H/H: 12.6/37.8; PLT: 200 Coagulation studies: PT/INR: 14sec./1.1; PTT:34.3sec. D-Dimer: 0.80ug/mL (elevated)
Image of page 4
A D-dimer test measures a substance in the blood that's released when a blood clot breaks down. High levels of the substance may mean a clot is present (National Heart, Lung, and Blood Institute, 2014). Troponin: <0.01 A troponin test measures the levels troponin T or troponin I proteins in the blood which are released when the heart muscle has been damaged, such as occurs with a heart attack (U.S. National Library of Medicine, 2015). EKG: Sinus tachycardia with non-specific T waves. Bilateral lower extremity venous Doppler: Right lower extremity deep venous thrombosis present. Chest X-ray: showed a small pleural effusion on the right base. The right diaphragm is elevated. Evidence of pleural air can be an indication of pneumothorax whereas, parenchymal infiltrate may suggest pneumonia (Baumann, Dains, & Scheibel, 2016, p. 89). Ventilation-perfusion (V/Q) scanning: the first line diagnostic tool for detecting pulmonary embolism which uses a radioactive substance to show how good oxygen and blood are flowing to the lungs (Baumann, Dains, & Scheibel, 2016, p. 89). In the incident of pulmonary embolism: report of high probability will show on the test. CT ANGIOGRAM PULMONARY: prominent main pulmonary artery segment evidence of pulmonary embolus. No evidence of thoracic aortic aneurysm. A. Differential Diagnoses (DD):
Image of page 5
Pulmonary embolism: is a sudden blockage in a lung artery which usually begins by a blood clot in a deep vein of the leg that travels to the lung from a vein in the leg with major causes like prolonged sitting, immobility, and post surgeries (National Heart, Lung, and Blood Institute, 2014). Signs and symptoms of pulmonary embolism (PE) include unexplained shortness of breath, problems breathing, chest pain, coughing, or coughing up blood and irregular heartbeat (National Heart, Lung, and Blood Institute, 2014). As all these symptoms are present with Mr. Hendricks pulmonary embolism is the primary diagnosis for the patient. Pneumothorax: results from the presence of air or gas in the pleural cavity with unexplained persistent tachycardia and breath sounds over pneumothorax are distant (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 288). Although the presence of
Image of page 6
Image of page 7

You've reached the end of your free preview.

Want to read all 8 pages?

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture