ADMITTING HISTORY A 52-year-old male factory worker

ADMITTING HISTORY A 52-year-old male factory worker was apparently in good health until about 2 months before admission, when he developed a cough, which was productive of moderate amounts of yellowish sputum. The cough was most severe in the morning but persisted throughout the day. He also complained of general malaise and reported a recent weight loss of 5 pounds. He had no night sweats and was afebrile. He was seen by his private physician and was treated with antibiotics. No chest x- rays were taken, but the physical examination was described as being within normal limits. On a follow-up telephone call 1 week later, the patient reported some improvement. Over the next 2 weeks, however, the patient developed moderate shortness of breath and marked hoarseness. He had no history of exposure to industrial irritants, but he admitted to a moderately heavy intake of alcohol and had a smoking history of 50 pack-years. As his symptoms persisted, he was admitted to the pulmonary clinic for evaluation. PHYSICAL EXAMINATION On physical examination, the patient was a well-developed, mildly obese middle- aged male who appeared slightly older than his stated age. He was in obvious but not severe respiratory distress. The patient coughed frequently, producing a moderate amount of white and yellow mucus. His vital signs were as follows: heart rate 125/minute, blood pressure 155/95, and respiratory rate 28/minute. One examiner believed that there was cyanosis of the lips, fingers, and toenails. The patient’s voice was distinctly husky. The trachea was slightly deviated to the right side, and indirect laryngoscopy revealed paralysis of the left vocal cord. The right lung fields were dull to percussion, and there were markedly diminished breath sounds on this side. Expiration was prolonged, and scattered wheezes were heard throughout. A chest x-ray showed a large mass greater than 3 cm in diameter at the right hilum and atelectasis with mild loss of lung volume on the right. The physician asked the respiratory therapist to document this information as he prepared the patient for bronchoscopy and biopsy. He also indicated that he planned to obtain secretions for cytology and routine cultures during the bronchoscopy. Based on the above clinical data, how would you SOAP this patient? (SOAP 1) SCIENCE HEALTH SCIENCE NURSING RESPIRATORY THERAPY RT220

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