Denies syncope MUSCULOSKELETAL Denies recent strenuous activity or trauma to

Denies syncope musculoskeletal denies recent

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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.
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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.
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