Clinical Documentation Template

Subjective

Chief Complaint: chest pains, difficulty in breathing, chest tightness, shortness of breath.

HPI: She reports to have been well until 6 days ago when she developed difficulty in breathing with mild chest pains and tightness. The pain was on the left side of the chest and radiated down the abdomen and to the back. Coughing, taking deep breaths and involving in any activity worsened the shortness of breath, difficulty in breathing and chest pains as well as tightness. Resting in an upright position such as sitting in a chair relieves the pain and respiratory difficulties. She attended one of the private clinic and she was given antihistamines to ease chest tightness and analgesics to relieve the pain. 

ROS

Constitutional: no weight loss, (+) chills, (-) fever, (+) generalized body fatigue.

Integumentary: (+) cyanosis of the lips and the skin.

HEENT: (-) headache, (+) lightheadedness, (+) confusion and dizziness, (-) vision changes, (-) excessive tearing, (+) sore throat, (-) ear pain, (-) discharge from the ears or deafness, (+) nasal flaring, (-) discharge or obstruction in the nose.

Neck: (+) Jugular Vein Distention, (-) neck stiffness, (-) swollen lymph nodes, (-) swollen thyroid glands.

Cardiovascular; (+) tachycardia, (+) hypotension, (+) chest pains.

Respiratory; (+) apnea, (+) tachypnea, (+) dyspnea, (+) chest tightness. 

Gastrointestinal: nausea and vomiting, absent, diarrhea, and constipation absent. Abdominal pains also absent.

Genitourinary: (-) pain during micturition, (-) incontinence, no discharge, no swelling, or edema. (-) foul-smelling.

Musculoskeletal; (-) joint inflammation, no limited range of motion, (-) joint pains.

Neurologic: (+) confusion.        

Psychiatric: (-) mood changes, (-) hyperactivity.

Hematologic; (-) excessive bleeding from cuts and bruises, (-) blood transfusion.

Endocrine: (-) glucose intolerance.

PHYSICAL EXAMINATION

General; the client is well dressed, with appropriate weight according to height and age.

Vital signs: temperature- 98.6F, blood pressure 106/61 mmHg, Respirations 26 cycles per minute, Pulse rate 103 beats per minute.

Skin: cold, bluish in color and dry.

HEENT: Head is normal in shape and size, covered with black and soft hair that is equally distributed. The scalp is free from lesions, lies of tenderness. Eyes are symmetrically placed on the same levels with ears. Conjunctiva and sclera are free from inflammation and discharge. Extraocular movement is normal. Ears are free from pain, discharge, obstruction, and or deafness. The nose has slight flaring but free from inflammation and or obstruction. Polyps are absent with a centrally placed nasal septum. The throat is positive for soreness, evidenced by productive and painful cough.

Neck: moves from side to side as well as free extension and flexion. There is no limited range of motion. Lymph nodes are free from swelling. There are distended jugular vein characteristics of fluid overload in the thoracic cavity.

Heart: weak tachycardia is present. There is hypotension with an increased pulse rate.

Lungs and chest: distant to absent breath sounds. Adventitious breath sounds specifically crackle, and wheezing is present. There is reduced tactile fremitus. Use of accessory muscles to breath. 

Peripheral Vascular System: The radial pulse is weak and faster. Cyanosis is evident in the lips, hands, and legs.

Abdomen: free from scars, distension, and tenderness. Bowel sounds present.

Musculoskeletal: symmetrical extremities, free from joint pains and swelling. Edema of the ankles is absent — cyanosis of the soles and palms.

Neurologic: oriented to time, place, and person. Glasgow Coma scale of 15/15

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Past Medical History: positive history of COPD four years ago. Positive history of pneumonia and asthmatic attack two years ago. No history of blood transfusion.

Surgeries: no history of minor or major surgical operation.

Hospitalizations: has two histories of hospitalization over respiratory conditions

Allergies: allergic to cold.

Medications: on Paracetamol and cetirizine. Both PO medication the she was given when she visited the clinic.

Family History: history of asthmatic attack in her father. Her mother was diagnosed of COPD 16 years ago and was treated to complete recovery.

Social History: not married and lives alone. Smoke cigarette and consumes alcohol.

Objective

PHYSICAL EXAMINATION

Labs: Chest Radiography.

General; the client is well dressed, with appropriate weight according to height and age.

Vital Signs: HR: 103 beats per minute.     BP: 106/61mmHg RR: 26 cycles per minute.       Pain: 8/10             Height: 161cm       Weight 140bs BMI: 25      SpO2; 88% Temperature; 98.2F

Skin: cold, bluish in color and dry.

HEENT: Head is normal in shape and size, covered with black and soft hair that is equally distributed. The scalp is free from lesions, lies of tenderness. Eyes are symmetrically placed on the same levels with ears. Conjunctiva and sclera are free from inflammation and discharge. Extraocular movement is normal. Ears are free from pain, discharge, obstruction, and or deafness. The nose has slight flaring but free from inflammation and or obstruction. Polyps are absent with a centrally placed nasal septum. The throat is positive for soreness, evidenced by productive and painful cough.

Neck: moves from side to side as well as free extension and flexion. There is no limited range of motion. Lymph nodes are free from swelling. There are distended jugular vein characteristics of fluid overload in the thoracic cavity.

Heart: weak tachycardia is present. There is hypotension with an increased pulse rate.

Lungs and chest: distant to absent breath sounds. Adventitious breath sounds specifically crackle, and wheezing is present. There is reduced tactile fremitus. Use of accessory muscles to breath. 

Peripheral Vascular System: The radial pulse is weak and faster. Cyanosis is evident in the lips, hands, and legs.

Abdomen: free from scars, distension, and tenderness. Bowel sounds present.

Musculoskeletal: symmetrical extremities, free from joint pains and swelling. Edema of the ankles is absent — cyanosis of the soles and palms.

 Neurologic: oriented to time, place, and person. Glasgow Coma scale of 15/15

Assessment

Differentials 

1. Pneumothorax 

Pneumothorax refers to a collapsed lung following the leakage of air into the pleural cavity. The air in this cavity compresses or pushes the longs towards the inner side resulting in its collapsing. A collapsed lung cannot perform its normal function. It occurs from several factors such as trauma to the chest or any underlying medical condition that result in airflow into the thoracic cavity (Pneumothorax – Symptoms and causes, 2019). Patients with pneumothorax usually present with chest pains and tightness, shortness of breath, and peripheral cyanosis (Pneumothorax: Practice Essentials, Background, Anatomy, 2019). The above patient presents with shortness of breath and chest pains symptoms similar to those of pneumothorax. Hence, pneumothorax should be considered as one of the diagnoses for the above patient.

2. Pneumonia 

Pneumonia is a disease involving the inflammation of lung parenchyma. The inflammatory process results in the widening of the chest cavity as well as the obstruction of the airways due to bronchial narrowing and obstruction from the exudates of the inflammatory process. As a result, patients will complain of shortness of breath, chest pains, and also tightness (Ciamberlano, Morrone & Martelli, 2016). Due to impaired gaseous exchange, there will excessive oxygen demand as compared to the available. The patient will take, therefore, breath faster to meet this demand (Pneumothorax: Practice Essentials, Background, Anatomy, 2019). In extreme situations, there will be cyanosis of the lips and the palms. For the above client, all the symptoms are similar to those of pneumonia; hence, this condition should be considered as one of the differential diagnoses.

3. Pulmonary Embolism 

Pulmonary embolism is a condition characterized by obstructed pulmonary artery due to the presence of a blood clot. Obstruction of blood flow into the lungs is the main reason behind the observed symptoms in patients with this condition. Patients with this condition usually present with chest tightness and pains. Shortness of breath is another characteristic finding in patients with pulmonary embolism (Pneumothorax – Symptoms and causes, 2019). With this condition, the heart will contract faster than usual in a bid to empty blood into the lungs against the obstruction. As a result, tachycardia is experienced. The blockage of blood flows out of the heart result in overload in the heart, which blocks the systemic venous return of blood. As a result, jugular vein distension is observed in patients (Ciamberlano, Morrone & Martelli, 2016). The client is positive of several symptoms of pulmonary embolism; hence, this condition will be considered as one of the probable diagnosis.

Diagnosis:

Spontaneous Pneumothorax

The client presents with shortness of breath and right-sided chest pain that worsens with deep breathing and activity. The pain is sharp and severe, rated at eight out ten, and radiates to the back. Chest tightness is also present according to her description. Objective assessment revealed other systemic symptoms. She was cyanosed with dry and cold skin. On palpation, her radial pulse is weak and faster than usual. Auscultation of the chest is positive of wheezing and crackles, and, negative of breath sounds. Jugular vein distention is positive on examination. Sore throat is evident from persistent cough with mucus produced. Based on the findings of objective and subjective assessment, the client is suffering from spontaneous pneumothorax.

Spontaneous pneumothorax, as the name suggests, refers to the sudden collapse of the lungs. The collapse result from air or gas that escapes from the air sacs in the lungs to the pleural cavity. The primary effect of this phenomenon is impaired gaseous exchange in the lungs resulting in shortness of breath (Vallejo, Romero, Mejia & Quijano, 2019). Impaired ventilation in the lungs prompts the patient to breath faster to meet the oxygen demands of the body and to eliminate the carbon dioxide from the lungs. As a result, patients will present with tachypnea. Due to poor ventilation, there is inadequate oxygen supply to the tissue resulting in cyanosis. Limited oxygen supply to the brain cells results in confusion and lightheadedness (Pneumothorax: Practice  Essentials, Background, Anatomy, 2019).An air-filled pleural cavity causes chest congestion hence the presence of chest pain and chest tightness. Thoracic congestion affects blood flow in and out of the heart. As a result, there is an increased heart rate to empty blood out of the heart against thoracic resistance. Due to the cardiac overload, blood returning to the heart will be blocked; hence, the presence of jugular vein distension (Pneumothorax – Symptoms and causes, 2019). 

Plan

Diagnostics

 Chest radiography such as ultra sound, MRI and CT scan.

Treatment

Oxygen therapy to promote effective gaseous exchange to meet the oxygen demand by the tissues. Analgesic therapy using morphine to relief pain. Doxycycline to promote adherence of the collapsed lung to the chest wall (Pneumothorax: Practice  Essentials, Background, Anatomy, 2019).

Education

During discharge, the patient is given some drugs to continue with the treatment process at home. It is, therefore, essential to educate the patient on how to take this medication and the importance of adhering to the prescription guidelines. Spontaneous pneumothorax can recur due to exposure to the trauma of the chest. Hence, the client should be advised to avoid certain activities that her risk of developing another incident of lung collapse (Kelly, 2019). The patient should be reminded of the importance of maintaining total bed rest during the therapeutic period. This will enable the lungs to adhere to the chest wall adequately. Patient should encourage to quit smoking and alcohol use.

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