Jorge Reyes 48 year old male who was born in Jalisco, Mexico, moved to West Sacramento when he was 5 years old. Went to grade school and middle…

Question Answered step-by-step Jorge Reyes 48 year old male who was born in Jalisco, Mexico, movedto West Sacramento when he was 5 years old. Went to grade school and middle school in West Sacramento but transfer to Sac High to play football. He then attended Junior College at Sac City College. He then went on to the police academy. He now works as a highway patrol man on nights in the route 5 and 99 sector. He had a wife and three children ages 2, 4, and 6 all boys with only the 6 year old going to school. Mom is a stay at home mom. She is now adding to the family income by taking care of 4 preschoolers, Monday through Friday for the past two months. He tries to get home in time for the dinner meal with his family if he is in the area. His days off are Monday and Tuesday. They are catholic and attend service each week and he attends when he can. He and his wife try to (go out once a week and play softball or basketball with a group of their friends). In high school, he was on the football team and also played some baseball. Mrs. Reyes’ mother-in-law comes to watch the children the night they got out but the children attend the ball games with their parents.Family history: father, age 70 has hypertension and on medication for the past 5 years and is well controlled, Mother has diabetes type 2 on medication and her blood sugars are poorly controlled and she says she is trying but loves to eat rice and beans, sister is 30 no current health problems except obesity. Sister has two children ages 4 and 6 who are friends with Jorge’s children. They all live within 5 miles of each other. Mr. Reyes’s family still live in Mexico and come to visit once a year for a month. (This sometimes adds a strain on his marriage as his parents think his wife should be working more to help with the income and then their son would not have to work so hard)He comes into your clinic because he has problems with his asthma. He has not had prior problems since high school but now is wheezing, short of breath with any effort like walking fast or climbing stairs. When he was small he remembers going to the hospital because he could not breathe but does not remember if he stayed the night or what treatment he had. Currently he has a headache, chills, sneezing and nasal congestion which is making it hard for him to go to work. He was off the whole weekend and spent most of the time in bed. Did take some over the counter medication, Claritin D, and Robitussin which did not seem to help. No one else in the home has the same symptoms. He did not sleep well the last 2 nights. He has been tested negative for Covid-19.Today, he states that he felt chest tightness and some discomfort in his left arm. He thought this was from playing baseball the past weekend. If he sits down the pain is less, returns as soon as he does any lifting.As far as his past medical history he has been overweight for the past 5 years, also has had bronchitis in 2015. Prior to that he was a smoker for 10 years but quit in 2015, smoking about a pack a day.(10 pack years) Occasionally has a beer or two on the nights especially when they play softball and holidays.He does not take any regular medication except an occasional Advil for discomfort after he plays baseball.You note in the chart that he has not had his flu shot.Vital signs: T: 101.6, P: 98 R: 24, BP 140/88, O2 stat is 96 % on room air (flocculates between 94% and 96%)Physical: pale, sweaty skin, says he cannot hear well out of his ears and has cloudy nasal exudates, enlarged turbinate’s, there is no rash on chest, lungs coarse breath sounds with expiratory wheezes throughout his lung fields. Tactile fremitus on lower back has increase vibrations. Heart irregular rhythm no murmurs, abdomen bowel sounds heard WNL some tenderness to palpation over his liver. He has a slight headache when he bends over to tie his shoe. He is coughing every once in a while as you are taking the history. The coughing has begun to hurt his chest. There is now a change with latest sputum and it has a slight streak of blood in it. Which is the main reason he is here today.Lab results: Chest x-ray show an infiltrate in the right lower lobeCBC: WBC is 15,000 with 75% neutrophils 1% monocytes 20% lymphocytesRapid strep is negative for Beta hemolytic strepO2stats are 96% on room airEKG shows normal sinus rhythmDiagnosis: PneumoniaPlan: Augmentin 875mg every 12 hours​Flovent MDI 2 puffs every 12 hours​Albuterol MDI 2 puffs every 4-6 hours as needed for wheezing and to be used prior to Flovent​Breathing treatment was given prior to patient leaving with Xopenex with relief of coughing and wheezing​Increase fluids and rest, off work for an additional 48 hours​To come to be rechecked prior to return to work​Gave work excuse for 48 hours​To go to ER or RTC if not having chest pain or Shortness of breathe.Fill out a Clinical Reasoning packet and ISBAR document with the above data. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)