How would the subjective and objective of

How would the subjective and objective of the information below be written as summary Name: Date:11/23/2022 Patient Initials:_LS _Age:_30 Gender: M I Health History-Subjective Data (yes no answers-all yes answers explain) Thorax and Lungs & Heart 1. Do you have a cough? No 2. Any shortness of breath? No 3. Any chest pain with breathing? No 4. Any chest pain or tightness? No 5. Do you seem to tire easily?__No 6. Do you sleep with more than one pillow? Yes, Client states that he sleeps with two to three pillows. 7. Does your skin ever turn blue or ashen?__No 8. Do you have any swelling of the feet or legs? No 9. Do you awaken at night to urinate? Yes, Client states he urinates once or twice at night 10. Ever smoke cigarettes? How many/per day? Alcohol use? Number of Drinks a Day? No, client denies use of smoking or drinking. 11. Any living or work conditions that affect your breathing? No 12. Last TB skin test, chest x-ray, flu vaccine? _10/22/2022 13. Any past history of heart or lung disease? No 14. Assess personal and familial cardiac risk factors: diabetes, hypertension, smoking, high cholesterol, obesity, sedentary lifestyle, age? Client states that his father has hypertension and high cholesterol. II Physical Exam-Objective Data-Thorax and Lungs & Heart A. Inspection 1. Thorax cage- Symmetrical, no deformities noted 2. Respiratory rate and pattern- RR16 and unlabored 3. Overall skin and nail color-Appropriate to genetic background. Warm to touch. Lips and Nailbeds are pink. Free of pallor and cyanosis. Consistent with genetic background. No lesions noted. 4. Patient’s position- Relaxed and sitting upright. 5. Facial Expression-Atraumatic in appearance 6. Level of consciousness-Alert oriented x3 B. Palpation 1. Confirm symmetric chest expansion- Symmetric bilaterally 2. Tactile fremitus- Equal throughout in all lung fields. 3. Detect any lumps, masses or tenderness-No lumps masses or tenderness noted. 4. Trachea- Midline, equally bilaterally C. Auscultation 1. Listen to anterior, posterior and lateral lung sounds- Anterior and axillary lung fields are clear. 2. Note any adventitious lung sounds? No adventitious sounds noted. D. Carotid Arteries 1. Palpate and grade R_2+ L 2+ equally bilaterally (0=absent, 1+=weak, 2+=normal, 3+=increased,4+=bounding) 2. Auscultate the carotid arteries for Bruits- No Bruit noted. E. Precordium 1. Skin color and condition-Appropriate to genetic background. Goes back normal position less than three seconds. No lesions noted. 2. Chest wall pulsations- Absence of vibratory sensations. 3. Heave or lift- No Heave or thrill noted. E. Precordium continued 4. Note Location: Palpate the apical impulse in the mitral valve or fifth intercostal space at the midclavicular line. F. Auscultation 1. Rate and rhythm-61bpm. Light thumping, with unlabored breathing. 2. Note any murmurs- No murmurs or extra heart sound noted. (Auscultate heart sounds in the aortic, pulmonic, erb’s point, tricuspid and mitral area) SCIENCE HEALTH SCIENCE NURSING NUR 334

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