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Posted: February 3rd, 2022
Health Assessment Case Study #3
M.C. is a 69-year-old man who presents to the outpatient office with a hacking, raspy cough.
Subjective Data
PMH: HTN, DM
Cough is productive, bringing up green phlegm
Runny nose, sore throat
Denies fever
Sore throat pain when swallowing
No history of smoking or seasonal allergies
Complains of fatigue
Objective Data
Vital signs: T 37 P 72 R 14 BP 134/64
Lungs: + Rhonchi bilateral upper lobes, wheeze
O2 Sat = 98%
Ears = TM bulging
Nose = + erythema, yellow discharge
Throat = + erythema, – pustules
Medications: Metoprolol 12.5 mg per day, Glucophage 500 mg twice a day
1. What other questions should the nurse ask about the cough?
2. Develop a problems list from the objective and subjective data.
3. What should be included in the plan of care?
4. What risk fac
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