What is the relevant objective and subjective assessment

Reference no: EM133563281

A 58 year-old male with a 10-year history of hypertension presents to the ER with dyspnea and dry cough that has been progressively worsening over the last 6 months. Initially he experienced dyspnea only after a brisk 1-mile walk. He now has dyspnea climbing up the flight of stairs to his bedroom. Lying down worsens symptoms, and he often needs three or four pillows to fall asleep.

On exam, he is afebrile, BP is 170/100 mmHg, respiratory rate is 20 breaths per minute and pulse is 80 beats per minute and regular. Auscultation of the heart reveals an S3, S4 and a 1/6 blowing holosystolic murmur heard best at the apex that radiates to the axilla. Point of maximal impulse is displaced to the left. There are scattered rales and wheezes on lung exam. There is 9cm of JVD. The liver edge is tender and 4cm below the costal margin. He has marked peripheral edema.

What is the relevant objective and subjective assessment data from the case study?

Reference no: EM133563281

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