CASE STUDY: Mr. KC Galas, 45 years old, married, was admitted to the Emergency Room of the Burayok Medical Center accompanied by his wife with chief complaint of difficulty of breathing. He was gasping for breath; his face was pale and was looking weak. He was seen holding his chest and very irritable. When interviewed, he told Nurse Ali Mango, Masakit and dibdib ko at nahihirapan akong huminga. The nurse observed that he was coughing profusely with thick copious phlegm. During assessment, the nurse got the following results: Temperature- 38.5 degrees celsius, Respiratory Rate- 32 cpm, Pulse Rate- 95 bpm, BP- 150/90 mmHg; Height- 57 and weight 190 lbs. When asked to rate the pain , the patient rated it 8 from a pain scale of 10 being the highest. Further interview revealed the following results:
Productive cough started 5 days ago; client self medicate with Loviscol cough syrup 1 tbsp 3x a day. One day prior to admission client experienced difficulty of breathing but afraid to be admitted to the hospital; one hour prior to admission , client complained of chest pain, hence, asked for admission
Hospitalized in 2005 due to pneumonia
With complete immunization
Allergic to dust and pollen
Father died due to heart attack, mother has diabetes mellitus
Happily married for 20 years with 3 children
Manager of a manufacturing company working on the night shift
Smokes for 20 years , consuming 1 ½ packs a day
Eats mostly meat, seldom eats fish and vegetables
Drinks 5 to 6 glasses of water per day
With regular bowel movement; no problem with urination
Goes to the gym once a week
Religion: Catholic
Hobbies: watching TV (his favourite show Encantadia) and reading. Identify the subjective and objective data?
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