Respiratory Case Study

Ramon Chu is a 65 year old Asian man who is admitted to the respiratory unit with exacerbation of emphysema. He has had the disease for 10 years and is well known since the hospitalizations have become more frequent. He presents this time stating “I can’t get my breath. I have a cough, fever and my chest hurts.” Your general survey reveals a frail, thin man on oxygen with obvious shortness of breath at rest. He is pursed-lip breathing. His wife comments “here we go again?” You take him to his room and make him as comfortable as possible before beginning his admission assessment. You notice that Mr. Chu is in mild to moderate respiratory distress and noticeably restless. Continue the assessment of this client.

 

Advanced Health Assessment Case Study

Presentation Guidelines and Grading

 

1.    Identify the subjective and objective data in the case (10%)    _______

2.    Describe additional information that needs to be obtained. This includes additional subjective and objective data that still need to be obtained and the identification of the systems that need to be investigated (15%) ________

3.    Identify differential diagnoses including diagnostics necessary to verify diagnosis (20%)                               _________

4.    Formulate Problem list (no more than 3 problems) (15%)        _________

5.    Discuss relevant pathophysiology of the main problem identified (15%)   _________

6.    Describe developmental, socioeconomic, psychosocial and cultural considerations as indicated (15%)                    _________

7.    Discuss plan of care including, but not limited to: Nonpharmalogical, Pharmacological, Educational, Follow-up and Referral components including interprofessional perspectives as indicated. (10%)        _________

Total         _________