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Case Study 3

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Submitted By rebellily
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What were the symptoms this patient presented over the course of the illness?
The symptoms this patient presented over the course of the illness were: shortness of breath and chest pressure, productive cough, exertional dyspnea, cough with trace hemoptysis, and exertional fatigue.

What are the findings of the physical exam and what is their significance?
The findings of the patient’s physical exam were : oral temperature is 95.5 degrees F, pulse is 78 bpm, blood pressure is 96/86 mm HG., respiratory rate is 18 breaths/min. and oxygen saturation is 90% while breathing room air. The examination of his head and neck is normal He has decreased breath sounds in the right anterior lower lung fields, with no rales, wheezing, rhonchi, or rubs. His heart has a regular rate and rhythm, with no gallops, rubs or murmurs. His S1 and S2 heart sounds are normal. His abdomen is soft and non tender with normal bowel sounds and no organomegaly. The peripheral arterial pulses of all extremities are equal and palpable bilaterally. He has no edema, tenderness, or erythema in his extremities.
Their significance is that, with the exception of decreased breath sounds in the right anterior lower lung fields, all physical findings were normal. To me, this would indicate that more diagnostic test should be administered to the patient.

What diagnostic tests were completed what were the findings? Any significance?
The diagnostic test that were completed were :
Test: Complete blood cell count (CBC), basic metabolic panel, cardiac enzymes, and coagulation studies
Findings: Normal except his bicarbonate reading, which is 20mEq/L (normal range, 21-30 mEq/L).
Test: ECG
Findings: Normal sinus rhythm with an incomplete right bundle branch block and T-wave abnormalities consistent with anterolateral ischemia.
Test: Echocardiogram
Findings: Pulmonary hypertension,...

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