hief Complaint: fatigue, shortness of breath with productive cough
History of Present Illness: Alfonso Smith (pronouns he/him/his), a 74-year-old male, presents with complaints of fatigue, dyspnea, and a cough with yellowish-red tinged sputum. He was diagnosed with a viral upper respiratory tract infection 2 days ago and states, “I am getting worse.” Up to date with influenza and COVID vaccinations. Negative influenza and COVID tests.
Medications: Multivitamin, ferrous sulfate, calcium carbonate, metformin, Lipitor
Past Medical History: type 2 diabetes mellitus, anemia, hypercholesteremia , COPD
Review of Systems:
General: Clean, well-groomed appearance
Neurological: Alert and oriented to person, place, time, and situation (A&O x 4)
Cardiovascular: Tachycardic. S1 and S2 are present, and the capillary refill is less than 3 seconds
Respiratory: Respirations shallow and rapid at rest; Inspiratory crackles
Gastrointestinal: Reports regular, daily bowel movements. Denies abdominal pain
Genitourinary: Denies any GI symptoms
Musculoskeletal: Denies any pain. Ambulates unassisted
Integumentary: Skin pink, warm, and dry
Allergies: None reported
Social History: Retired; lives with spouse
Family History: No significant family history was reported
Vital Signs: Temperature: 101.4 °F (38.6 °C); Heart rate: 102 bpm; Respiratory rate: 32 breaths per minute; Blood pressure: 136/76 mmHg; Pulse oximetry: 95% on room air
Complete the following sentence by choosing from the list of options.
Based on the client’s history, the nurse practitioner (NP) should recognize that the client is experiencing complications of