Subjective and Objective Documentation based on Christopher Parrish -THORAX AND LUNGS
I. Health History (30 points)
Patient Name
Reason for
Visit
Christopher Parrish
Age
18
Gender
Male
Respiratory distress and SOB related to Cystic Fibrosis
SUBJECTIVE HISTORY: WRITE A PARAGRAPH SUMMARIZING YOUR FINDINGS USING THE
PQRSTU FORMAT and SBAR FORMAT (30 points)
P: Patient states that pain worsens with movement and deep breathing and pain improves with rest and pain
killers
Q: Patient describes the pain as tender and achy.
R: Pain is localized to chest and back
S: Patient rates pain a 3/10 while on pain killers
T: Pain started overnight and has been persistent
U: Patient understands this is related to his cystic fibrosis
S:
Christopher Parrish is an 18-year-old male with cystic fibrosis who presented to the ED overnight for
respiratory distress and increased work of breathing. He is currently on 2 L of oxygen via nasal cannula.
B:
Patient was diagnosed with cystic fibrosis as an infant and had had frequent pervious hospitalizations. At
admission, he reported SOB, fatigue, and difficulty clearing secretions. His oxygen saturations were 85-87% on
room air when he arrived to the ED.
A:
Patient states shortness of breath and fatigue with tender/achy pain to chest/back.
R:
Continue to encourage the patient to perform coughing, diaphragmatic breathing and other respiratory exercises.
II. Physical examination (OBJECTIVE DOCUMENTATION): WRITE PARAGRAPH
SUMMARIZING YOUR OBJECTIVE FINDINGS IN THE CHRISTOPHER PARRISH CASE.
REMEMBER TO USE ALL THE OBJECTIVE FINDINS IN Inspection, Percussion, Palpation,
Auscultation. IF THE VSIM AVATAR SCENARIO DOES NOT HAVE RELATABLE FINDINGS
THAN WRITE WHAT THE NORMAL PHYSICAL EXAMINATION FINDINGS WOULD BE.
(40 points).
____________________________________________________________________________________
Inspection:
Mild subcostal retraction and no lesions, scarring, vein distension or visible pulsations of skin. The color was normal to
patient’s ethnicity, no odor was present, and skin integrity was intact, and no hair was present. Nose has no visible deformities,
lesions, swelling or discharge. No nail clubbing or cyanosis on nails.
Palpation:
Thorax was smooth, warm, dry and mobile with normal turgor and chest is a bit tender.
Percussion:
No percussion was assessed on this patient.
Expected physical examination findings on percussion for this patient would include hyperresonance over lungs due to air
trapped related to cystic fibrosis. Localized dullness in lower lung fields due to mucus buildup also related to cystic fibrosis.
Normal findings:
Normal physical examination findings on percussion would include resonant lung sounds over the chest, indicating healthy
lungs. The absence of dullness suggests no fluid accumulation. Over the cardiac area, normal percussion findings would
demonstrate a relatively dull sound due to the heart's position.
Auscultation:
Crackles were heard in the lower part of the lungs and no murmurs were heard over heart and S1 and S2 present with no
splitting.