Concepts II
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
STUDENT NAME: Imee Price DATE/ Clinical: 9/5/24 Instructor Name:
E Hall ALLERGIES/ Reaction to: no known allergies
PATIENT INITIALS: MB LMP: N/A
ADMISSION DATE: 9/2/24
AGE: 66 GRAVIDA: N/A PARA: N/A AB: N/A
PAIN: Is client experiencing any pain? Y
Verbal/nonverbal RELIGION: How does it affect their care?
PT did not Disclose; If religious beliefs were disclosed, I would
Pain Scale used: 8/10 provide care that stays within those beliefs
Location: Chest and Left Arm
Duration: 4 weeks Height: 5’ 9” Weight: 161 BMI: 23.8
Character: pressure in chest and discomfort in arm
CHIEF COMPLAINT in PT’s own words: Pt stated, “I can’t breathe”
HISTORY OF PRESENT ILLNESS
How, when, where, what and why; of the chief complaint
PT presented to ER c/o shortness of breath; PT did not disclose onset or precipitation of
discomfort; PT describes pain as pressure in chest and discomfort in arm; PT rated pain as 8/10;
problem has been going on for 4 weeks and is getting progressively worse.
PAST MEDICAL HISTORY
PT has history of Pulmonary Edema, Hypoxia, HTN, HLD, Paroxysmal Atrial Fibrillation – post
ablation therapy (Oct 2023), Endocarditis – post completed antibiotic therapy (June 2024), Gout,
Cardiac Catheterization performed in Oct 2023 should be noted, Severe Mitral Valve Disease –
post mitral valve replacement, COPD, Chronic Systolic and Diastolic CHF – last ejection
fraction noted to be 50% in June 2024
CURRENT ORDERS
DIET: NPO after midnight, exc meds with sips of water – until after scheduled TEE – Then
limit fluid intake to 1200 ml/day
ACTIVITY: Activity as tolerated
TREATMENTS: BiPAP Therapy
1
TCD/10-07
, Time BP HR RR SPO2 Blood Sugars
Coverage
7:06 156 84 16 96 room air 129
71
11:01 146 84 17 97 room air 110
64
5:40 150 82 17 97 room air 103
77
PHYSICAL ASSESSMENT/ On Going throughout day
(Complete head to toe assessment. WNL and NORMAL are not accepted. Please be specific.)
HEENT Head is atraumatic, normocephalic. Pupils are equal, round, and reactive to light. Extraocular
muscles intact. Mucous membranes appear to be pink and moist. No oral lesions are noted. The
PT is with BiPAP therapy
Neurologic:
Respiratory: PT is noted to have rales throughout lungs, Fair air movement is noted, however.
Cardiovascular: Regular rate and rhythm with no audible rubs or gallops noted
Gastrointestinal: Abdomen was soft, no tenderness. Bowel sounds noted
Genitourinary:
Musculoskeletal: PT has 5/5 muscle strength in upper and lower extremities, 2/4 deep tendon reflexes in upper and
lower extremities. PT has significant edema in the lower extremities all the way up into the top
of the thighs bilaterally.
Integumentary:
Skin in overall good condition, noted some areas of concern due to tape allergy; PT takes regular
care of nails
Psychosocial: PT has great family support, has great hygiene, makes regular visits to her care provider and
specialists. PT was in a good mood and in high spirits
Nutritional: PT and daughter both report that PT eats a healthy diet
2
TCD/10-07
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
STUDENT NAME: Imee Price DATE/ Clinical: 9/5/24 Instructor Name:
E Hall ALLERGIES/ Reaction to: no known allergies
PATIENT INITIALS: MB LMP: N/A
ADMISSION DATE: 9/2/24
AGE: 66 GRAVIDA: N/A PARA: N/A AB: N/A
PAIN: Is client experiencing any pain? Y
Verbal/nonverbal RELIGION: How does it affect their care?
PT did not Disclose; If religious beliefs were disclosed, I would
Pain Scale used: 8/10 provide care that stays within those beliefs
Location: Chest and Left Arm
Duration: 4 weeks Height: 5’ 9” Weight: 161 BMI: 23.8
Character: pressure in chest and discomfort in arm
CHIEF COMPLAINT in PT’s own words: Pt stated, “I can’t breathe”
HISTORY OF PRESENT ILLNESS
How, when, where, what and why; of the chief complaint
PT presented to ER c/o shortness of breath; PT did not disclose onset or precipitation of
discomfort; PT describes pain as pressure in chest and discomfort in arm; PT rated pain as 8/10;
problem has been going on for 4 weeks and is getting progressively worse.
PAST MEDICAL HISTORY
PT has history of Pulmonary Edema, Hypoxia, HTN, HLD, Paroxysmal Atrial Fibrillation – post
ablation therapy (Oct 2023), Endocarditis – post completed antibiotic therapy (June 2024), Gout,
Cardiac Catheterization performed in Oct 2023 should be noted, Severe Mitral Valve Disease –
post mitral valve replacement, COPD, Chronic Systolic and Diastolic CHF – last ejection
fraction noted to be 50% in June 2024
CURRENT ORDERS
DIET: NPO after midnight, exc meds with sips of water – until after scheduled TEE – Then
limit fluid intake to 1200 ml/day
ACTIVITY: Activity as tolerated
TREATMENTS: BiPAP Therapy
1
TCD/10-07
, Time BP HR RR SPO2 Blood Sugars
Coverage
7:06 156 84 16 96 room air 129
71
11:01 146 84 17 97 room air 110
64
5:40 150 82 17 97 room air 103
77
PHYSICAL ASSESSMENT/ On Going throughout day
(Complete head to toe assessment. WNL and NORMAL are not accepted. Please be specific.)
HEENT Head is atraumatic, normocephalic. Pupils are equal, round, and reactive to light. Extraocular
muscles intact. Mucous membranes appear to be pink and moist. No oral lesions are noted. The
PT is with BiPAP therapy
Neurologic:
Respiratory: PT is noted to have rales throughout lungs, Fair air movement is noted, however.
Cardiovascular: Regular rate and rhythm with no audible rubs or gallops noted
Gastrointestinal: Abdomen was soft, no tenderness. Bowel sounds noted
Genitourinary:
Musculoskeletal: PT has 5/5 muscle strength in upper and lower extremities, 2/4 deep tendon reflexes in upper and
lower extremities. PT has significant edema in the lower extremities all the way up into the top
of the thighs bilaterally.
Integumentary:
Skin in overall good condition, noted some areas of concern due to tape allergy; PT takes regular
care of nails
Psychosocial: PT has great family support, has great hygiene, makes regular visits to her care provider and
specialists. PT was in a good mood and in high spirits
Nutritional: PT and daughter both report that PT eats a healthy diet
2
TCD/10-07
