Tuberculous-Pleural-Effusion-Case-Analysis-Group-2B-Final-Paper

III. NURSING HEALTH HISTORY A. History of Present Illness As reported by the patient, he was experiencing shortness of breath wherein it was the reason why he came to the hospital. Before his 4 days’ admission, the patient experienced shortness of breath which occurs in the afternoon after his work. It includes mild and productive yellow sputum cough and subjective weight loss, 2-pillow orthopnea, obstructive sleep apnea (OSA), Paroxysmal Night Dyspnea (PND). It is reduced by rest, but no consultation or prescription has been given. One night before admission the symptoms persisted and are now associated with abrupt onset of pleuritic chest pain and right upper-quadrant abdominal pain (VSA: 8/10) with non-association of nausea or vomiting which made the patient to consult to Rizal General Hospital where he was given several diagnostic tests such as chest & abdominal x- ray and ultrasound. The patient was diagnosed with pleural effusion and cholelithiasis with no cholecystitis. He was given unrecalled pain medications and nebulized before being referred to Alonzo Hospital for further evaluation and treatment. But, due to a lack of available resources and equipment, they advised being transferred to Valeriano Medical Center. Upon assessment, his vital signs showed an elevated respiratory rate of 26 cpm, temperature of 37.6 °C and oxygen saturation of 93 % which is considered as a deviation from normal. However, his blood pressure (110/70 mmHg) and heart rate (92 bpm) are within the normal range. B. Past Health History The client was diagnosed with hypertension in the year 2018 wherein he was advised to modify his lifestyle. In the year 1999, the client has been hospitalized for five days due to weakness felt after binge drinking of alcoholic beverages. Furthermore, the patient was involved multiple times in a minor motorcycle accident wherein hospitalization and surgery were not needed. During his childhood, the patient has received complete immunization and has suffered from measles and chickenpox/varicella. Upon the assessment, the patient does not have any allergies to food and medication. The client has not travel local and abroad. In addition, the client does not have a history of asthma or any known lung problem and heart disease. C. Occupational History Inclusive Dates/Years Occupation March 16, 2017- May 20, 2018 Construction worker (Ceiling installer) at Arkg Plumbing and Construction July 6, 2018- August 13, 2019 Delivery driver at JCTA Construction and Devt Corporation September 10, 2019- November 15, 2020 Construction worker at Presam Construction and General Services Inc.