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Documentation of problem based-assessment of the respiratory system-Mr-Zhang

Documentation of problem based-assessment of the respiratory system-Mr-Zhang

Chief Complaint: shortness of breath and fatigue.


The client is a sixty-eight-year-old Chinese male who presents to the hospital with complaints of shortness of breath and fatigue. The patient states that the symptoms started two weeks ago and they have persisted since then. He states that the shortness of breath is rapid. His symptoms are worsened by exercise and relieved by rest. He states that the symptoms are worse in the evening. He denies taking any medications to relieve his symptoms. The patient states that he is also coughing “stuff up.” The patient is currently on a thiazide diuretic and chlorthalidone for hypertension. He is also taking albuterol and ipratropium for his breathing issues. He is allergic to pollen and latex. The patient has a medical history of COPD and hypertension. He smokes 98 packs per year. Both parents of the patient are dead. His father died at 78 of diabetic complications, while his mother died at 60 of a stroke. His paternal grandfather died at 68 of hypertension, while his paternal grandmother died of hypertension at 80. Both his maternal grandparents succumbed to a road accident with no known medical history. He is married to one wife with two very healthy children. He is a Christian, and he is retired.


The patient is cooperative during physical examination but appears to be in distress. He has an oral temperature of 100 F, indicating fever. His heart rate is high with 112 BPM, while his respiratory rate is 24. He has a blood pressure of 157/78 mmHg and oxygen saturation of 88%. Inspection reveals an AP: T ratio of 1:1. His skin color is pale, and he is using his accessory muscles for breathing. An inspection of his fingers reveals clubbing. The patient is also coughing thick-yellow sputum. His chest walls are symmetrical, and there is no visible trauma in his head or skin. The nasal nares are patent, and the tympanic membrane is grey. His pupils are round and equal. His tactile fremitus is increased both anteriorly and posteriorly. The chest is non-tender with no chest expansion. His abdomen is non-tender. There are crackles in his right lower lob. The patient also has whispered pectoriloquy and bronchophony over the right lower lobe. There is E to A present over the right lower lobe. Chest walls are symmetrical.

Potential Risk Factors

The patient has a history of smoking 98 packs of cigarettes a year. Excessive cigarette smoking is harmful to the patient’s health and can predispose him to disability and harm. The health effects of smoking include cancer, lung disease, diabetes, chronic obstructive pulmonary disease, stroke, and heart conditions (West, 2017). It can also increase the risk of the patient getting conditions such as eye diseases, tuberculosis, immune conditions such as rheumatoid arthritis (West, 2017)

The patient has a history of COPD and based on the symptoms that the patient presented with and the physical examination findings; the presumptive diagnosis is COPD. COPD presents with dyspnea, cough, sputum, and wheezing (Miravitlles & Ribera, 2017). It is caused by cigarette smoking and exposure to irritants. COPD can result in respiratory infections, heart diseases, and lung cancer (Miravitlles & Ribera, 2017)

In summary, patient evaluation is beneficial since it helps healthcare professionals develop a diagnosis and implement care plans that can help treat the patient. They must thus conduct thorough history taking and physical evaluation to reveal information useful in developing patient-centered care plans.


Miravitlles, M., & Ribera, A. (2017). Understanding the impact of symptoms on the burden of COPD. Respiratory Research18(1).

West, R. (2017). Tobacco smoking: Health impact, prevalence, correlates, and interventions. Psychology & Health32(8), 1018-1036.


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Documentation of problem based-assessment of the respiratory system-Mr-Zhang

Perform a respiratory assessment. Document your subjective and objective findings, identify actual or potential risks,


  • Documentation of problem based assessment of the respiratory system.

Purpose of Assignment:

  • Learning the required components of documenting a problem-based subjective and objective
    assessment of respiratory system. Identify abnormal findings.

Course Competency:

  • Apply assessment techniques for the neurological and respiratory systems.

Content: Use of three sections:

  • Subjective
  • Objective
  • Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.


  • Standard American English (correct grammar, punctuation, etc.)

Respiratory Patient Case

Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation, but please use the following basic information to document about your patient:

Documentation of problem based-assessment of the respiratory system-Mr-Zhang

Documentation of problem based-assessment of the respiratory system-Mr-Zhang

Patient Case (subjective)
Mr. Zhang, a 68-year-old Chinese man
Chief Complaint: shortness of breath and fatigue.
Current smoker: 98 pack-year history of smoking
Past medical history: high blood pressure and COPD.
Medications: thiazide diuretic, chlorthalidone, for his high blood pressure. Albuterol and ipratropium inhalers for breathing.
Allergies: pollen and latex.
HPI: States he has increase in shortness of breath recently. He also says he is coughing “stuff up” Ask Mr. Zhang more OLDCARTS about his symptoms.

Physical Exam (objective)
Vital Signs: Oral Temp 100 F, HR 112 BPM, RR 24, and BP 156/78 mm Hg, SpO2 88%
Inspection: AP: T ratio 1:1. Skin color pale, using accessory muscles to breathe. Clubbing present in
fingers. Coughing up moderate amounts of thick-yellow sputum. Other inspection document as
normal/expected findings
Palpation: Tactile fremitus increased right bases anteriorly and posteriorly. Document rest of palpation
as normal/expected findings
Auscultation: Crackles in right lower lobe. Positive bronchophony and whispered pectoriloquy over right
lower lobe. Positive E to A change present over right lower lobe. Document rest of auscultation as “normal”

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