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Denies syncope.MUSCULOSKELETAL: Denies recent strenuous activity or trauma to leg or back. 8-hour plane trip 5 days ago.HEMATOLOGIC: No hx anemia, bleeding or bruising.LYMPHATICS: No enlarged nodes. No history of splenectomy. No history of HIV / immunosuppression.MENTAL HEALTH: No history of depression or anxiety. Denies prior episode of similar symptoms in the past 6 months.ENDOCRINOLOGIC: Recent A1C screening at health fair normal. ALLERGIES: No history of asthma. Reports seasonal allergies in spring.O.VS:T 97.9 O, RR 32 (labored), HR 112, BP 148/88 (right arm), SpO2 90% (RA), Wt 210 (stable), Ht 5’10”BMI 30.1General: well-developed, male dressed appropriately for the situation. Good historian. Appears anxious and in distress.Skin:“Cool, diaphoretic” (Walden, n.d., p. 1). No cyanosis or pallor noted. No lesions present on thorax.Thorax and lungs:AP diameter is less than lateral diameter. “Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds left lung” (Walden, n.d., p. 1). No use of accessory muscles during respiration.
Refuses palpation of thoracic expansion “it hurts too much.” Denies pain to palpation. No significant increase or decrease in tactile fremitus. Trachea is midline.Cardiovascular:“Heart rate is irregular with good S1, S2; no S3 or S4; no murmur” (Walden, n.d., p. 1). Cap refill 2 sec. upper and lower extremities.Abdomen:“Protuberant with normoactive bowel sounds auscultated x4 quadrants” (Walden, n.d., p. 1). Denies nausea or vomiting. No pain after meals or while supine.Peripheral vascular:“Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally” (Walden, n.d., p. 1).Neurologic:“Anxious; awake, alert, and oriented to person, place, and time” (Walden, n.d., p. 1).Musculoskeletal: Moves slowly with some guarding and splinting of right side in lower costal area. Arm length appears in normal length to height.Diagnostic results: Blood tests:-D-dimmer assay (DD). This blood test is reported by Dains, Baumann, and Scheibel (2016) to be useful as a screening test for thrombosis. Alhassan, Sayf, Arsene and Krayem (2016)note the testhas a high false-positive rate and recommended using an increased cutoff score to increase the accuracy of the results. Although not a definitive test for pulmonary embolism (PE), Huisman and Klok (2013) Suggested the sensitivity of DD is adequate for diagnosing a deep vein thrombosis (DVT) when accompanied by clinical symptoms such as redness, swelling, pain and heat. -PT/PTT. Will be used to monitor anticoagulant medications (Dains et al., 2016) if this client is found to have a PE/DVT. These are not useful tests until the diagnosis is definitive.