Mr. Hernandez is in the hospital with an admitting diagnosis of left lower lobe pneumonia. As part of the admission assessment, the nurse is preparing to perform a physical assessment of his skin, head, eyes, ears, nose, and throat. Mr. Hernandez has several missing teeth and wears a partial denture, which bothers him at times. He wears glasses to read but hasnâ€™t had an exam with an ophthalmologist for many years. He has occasional headaches, which usually go away on their own. He has spoon nails and ecchymosis on his lower left arm. He has a history of a tonsillectomy and adenoidectomy when he was 4 years old. He has frequent sinus congestion whenever there is a change in the weather.
Mr. Hernandez usually takes over-the-counter sinus medicine that will take care of the problem. He notes that he started with sinus congestion about two weeks ago that continued to get worse and made his throat sore from the drainage and the frequent coughing. He thinks this is why he developed the pneumonia that caused him to be admitted to the hospital this time. No other significant history was noted by the nurse during the interview.
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