NRNP 6568 Week 6 Assessing, Diagnosing, and Treating Patients With Complex Conditions  Patient Information: ED, 69 years, Male

Sample Answer for NRNP 6568 Week 6 Assessing, Diagnosing, and Treating Patients With Complex Conditions 

Patient Information:

ED, 69 years, Male

S.

CC (chief complaint): “Fatigue, fever, and chills”

HPI: ED is a 69-year-old male who presented to the facility complaining of fever, chills, and fatigue for the past few days. ED did not take his temperature but reported feeling hot. He expressed coughing up a little phlegm, pain when taking a deep breath, and changes in his appetite. ED has been taking Tylenol with minimal relief. He has been drinking teas to break up the phlegm. ED is a non-smoker and non-drinker.

Current Medications: ED has been taking Tylenol with minimal relief. He has been drinking teas to break up the phlegm.

Allergies: ED denied food, drug, or environmental allergies.

PMHx: ED denied a history of hospitalization or surgery. His immunization is up-to-date. He received his last tetanus toxoid vaccine more than a year ago.

Soc & Substance Hx: ED is a retired teacher. He is a non-smoker and a non-drinker. He is married. He lives with his wife and a dog. His hobbies include reading and visiting new places. He uses a seat belt when driving. ED does not have a gun at home. Their home has working smoke detectors. His family is his support system.

Fam Hx: ED reports his father died of chronic hypertension. His father also had type 2 diabetes mellitus. His paternal grandfather died from lung cancer. His uncle died from substance use disorder. There is no other significant family history.

Surgical Hx: ED denied any history of surgery

Mental Hx: ED denied any history of mental health problems, including depression and anxiety.

Violence Hx: ED denied any violence concerns.

Reproductive Hx: ED denied any history of sexually transmitted infections. He also denied urgency, frequency, or dysuria.

ROS:

GENERAL: The patient reports fever, chills, and fatigue.

HEENT: Eyes: ED denies visual changes, eye drainage, or eye pain. He denies hearing loss, nasal congestion, sneezing, sore throat, or runny nose.

SKIN: ED denies skin rash or skin itchiness

CARDIOVASCULAR: ED reports chest pain on inspiration. He denies palpitations, chest pressure, or discomfort.

RESPIRATORY: ED reports a productive cough with no shortness of breath

GASTROINTESTINAL: ED reports changes in his appetite. He denies nausea, vomiting, diarrhea, or constipation.

GENITOURINARY: ED denies burning on urination, urinary frequency, or urgency.

NEUROLOGICAL: ED denies headaches, dizziness, ataxia, or numbness. There is no change in his bladder or bowel control.

MUSCULOSKELETAL: ED denies joint pain or stiffness.

HEMATOLOGIC: ED denied anemia or easy bleeding.

LYMPHATICS: ED denied lymphadenopathy or a history of splenectomy.

PSYCHIATRIC: ED denies a history of anxiety or depression.

ENDOCRINOLOGIC: ED denies heat or cold intolerance, polyuria, or polydipsia

REPRODUCTIVE: ED denies penile discharge.

ALLERGIES: ED denies asthma, rhinitis, or allergic reactions

O.

Physical exam:

Vitals: BP 130/80, P 84, R 14, T103.2, SPO2 94%

Respiratory: The patient is not in visible respiratory distress. There is no nasal flaring. Auscultation reveals decreased rales and rhonchi, which are more pronounced in the left lower lung fields. There is increased dullness and fremitus to percussion. A chest x-ray reveals left lower lobe consolidation.

Cardiovascular: There is no cyanosis or lower limb edema. Auscultation reveals normal heart rhythm with no murmurs or skipped beats.

Diagnostic results: A chest x-ray was ordered. It revealed left lower lobe consolidation. A sputum culture and sensitivity should be ordered. This will help determine the bacteria associated with ED’s respiratory problem. It would also guide treatment decisions.

A.

Differential Diagnoses:

Pneumonia: Pneumonia is ED’s primary diagnosis. Pneumonia is an infection of the lung parenchyma caused by bacteria, fungi, or viruses. Patients present to the hospital complaining of malaise, fever, chills, myalgias, cough, and loss of appetite (Jain et al., 2024). Physical examination findings seen in these patients include tachycardia, tachypnea, decreased bronchial breath sounds, egophony, tactil