A 62-year-old male arrives at the emergency department accompanied by his wife. He reports increased shortness of breath with daily activities and exertion and feels more fatigued than normal. 

The nurse has reviewed the client’s history and physical and has documented his reported information regarding the purpose of his visit. The nurse is now determining the relevant information in order to address the needs of his acute condition. 

Click to highlight the subjective statements indicative of disease progression, requiring further investigation by the nurse.

Nurse’s Notes

The client reports the purpose of his visit is his increased shortness of breath and fatigue for the last two months. Increased work of breathing was noted with ambulation to the stretcher. Skin is pale and diaphoretic. The client states, “I gained 3 pounds this week without changes to my diet or activity routines. In fact, I don’t really have much of an appetite at all because I usually feel full.” He states that his shoes feel tight. Upon taking off his shoes, the nurse notices his socks leave an indentation around his ankles. The client also mentions an increase in urinary frequency overnight.