UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Ahsha Young |

|Patient Assessment Tool . |Assignment Date: October 4, 2015 |

| ( 1 PATIENT INFORMATION |Agency: Bayfront Medical Center |

|Patient Initials: D.W.R. |Age: 74 |Admission Date: 09/01/2015 |

|Gender: Female |Marital Status: Married |Primary Medical Diagnosis with ICD-10 code: Chest Pain (786.50) |

|Primary Language: English | |

|Level of Education: College |Other Medical Diagnoses (new on this admission): |

|Occupation (if retired, what from?): Home economics teacher, retired |Pulmonary embolism |

|Number/ages children/siblings: 2 Children – 1 boy (46), 1 girl (44); 2 brothers, 0 sisters | |

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|Served/Veteran: N/A |Code Status: Full |

|Living Arrangements: Lives with husband who takes care of her. She lives in a home with no |Advanced Directives: Yes |

|stairs, and the only safety issue is shower with 1 step (lip) to walk over |If no, do they want to fill them out? |

| |Surgery Date: 08/27/2015 – left total knee arthroplasty |

|Culture/ Ethnicity /Nationality: Caucasian American | |

|Religion: Lutheran |Type of Insurance: Well Medical |

|( 1 CHIEF COMPLAINT: “I just needed to get a knee surgery—my doctor scheduled it. It was an elective surgery.” “ They said I had a pulmonary embolism.” |

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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |

|On 08/31/2015, D.W.R was discharged from the orthopedic floor to a skilled nursing facility, following an elective surgery for a total left knee arthroplasty. |

|Upon discharge from that visit, her blood pressure and other vitals were stable. While at the rehabilitation center, the patient stated that she was having leg |

|pain and did not feel comfortable at the facility she was at. As a result, her anxiety levels increased and she developed anterior chest pain. On 09/01/2015 she |

|presented to the emergency room with uncontrolled/accelerated hypertension and complaints of chest pain. The patient described the pain as lasting for only about |

|an hour, but did not describe any other symptoms. An ISTAT troponin I level was normal but total CPK was critically elevated. Chest x-rays showed no evidence of |

|acute cardiopulmonary disease or acute pulmonary disease. She was eventually admitted to the progressive care unit for observation and to rule out a possible |

|pulmonary embolism (PE). 09:00 labs on 09/01/2015 revealed a D-dimer of 661 and a CT angiogram on 09/02/2015 confirmed the presence of a PE in the subsegmental |

|branch of the right lower lobe pulmonary artery. Ultrasound Doppler of the bilateral lower extremities showed no evidence of deep vein thrombosis (DVT). |

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|Now, 09/04/2015, D.W.R.’s plan of care includes continuing her on apixiban (Eliquis) for at least 3 months to decrease her risk of stroke/systemic embolism, |

|continuing CPAP at night for sleep apnea, and placing her back in a skilled nursing facility/rehabilitation center for continued rehabilitation of her left knee. |

|She still suffers from dull, achy pain in the left knee that is relieved by hydromorphone and discomfort at both hips/thighs that is relieved by a warm compress. |

|However, her chest pain is resolved, blood pressure remains stable, and she has no shortness of breath. |

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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation

|Date |Operation or Illness |

|08/27/2015 |Left total knee arthroplasty: dilaudid for pain, occupational therapy |

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|2002 |Right knee surgery; pain medication given for treatment along with rehabilitation |

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|2000 |Orthoscopic surgery – clean up jagged bone from arthritis |

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|1976 |Gallbladder removal (cholecystectomy) |

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|( 2 FAMILY MEDICAL HISTORY |

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|( 1 immunization History |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |

|Routine childhood vaccinations | | |

|Routine adult vaccinations for military or federal service | | |

|Adult Diphtheria (Date: U) | | |

|Adult Tetanus (Date: U) | | |

|Influenza (flu) (Date: U) | | |

|Pneumococcal (pneumonia) (Date) | | |

|Have you had any other vaccines given for international travel or occupational purposes? Please List | | |

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |None | |

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|Other (food, tape, latex, dye, |None | |

|etc.) | | |

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|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |

|genetic factors impacting the diagnosis, prognosis or treatment) |

|A pulmonary embolism (PE) occurs when a free floating substance (thrombus [blood], air, and/or fat) in the bloodstream, originating in another location in the |

|body, obstructs one of the pulmonary arteries. Emboli most commonly originate in the deep veins of the lower extremities (i.e. legs). The body’s response to a PE|

|can rely on various factors such as the size of the clot and the amount of emboli present, but smaller emboli are usually asymptomatic and resolve on their own |

|(Osborn, Wraa, Watson, & Holleran, 2014). On the other hand, larger emboli can cause serious issues like increased pulmonary vascular resistance and impaired gas |

|exchange (Domino, 2015). |

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|Major risk factors for PE include stagnation of venous blood, damage to the inner walls of the venous endothelium as well as increased blood coagulation. These |

|changes may come as the result of conditions such as prolonged bed rest or immobilization, surgery within the last 3 months, dehydration, paralysis, etc. Women, |

|in particular, have additional risk factors like smoking, obesity, and hypertension (Sommer & Fannin, 2015; Osborn et al., 2014). |

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|The most common clinical manifestations of PE are sudden onset of chest pain, dyspnea, and cough but other signs and symptoms may include leg pain, tachycardia, |

|fever, and diaphoresis (Mayo Clinic Staff, 2015). There is no one specific diagnostic procedure or laboratory test for diagnosing PE but, rather, a series of |

|tests that can be ordered to determine what underlying conditions may be present. Along with an arterial blood gas (ABG) and complete blood count (CBC), a D-dimer|

|lab test may be ordered to determine if the body is trying to actively break down blood clots. An abnormal value may indicate further testing is needed. |

|Additionally, diagnostic procedures such as a chest x-ray (CXR), computed tomography angiogram (CTA), or pulmonary angiogram (surgically invasive) can indicate the|

|presence of a PE (ATI Nursing Education, 2011). |

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|It is important to treat a PE as soon as possible in order to avoid further pulmonary issues and to prevent the occurrence of new emboli. Treatment will focus on |

|maintaining the patient’s airway and insuring there is adequate oxygenation to the lungs and administering anticoagulants to prevent the formation of more clots. |

|In advanced cases, an embolectomy or an inferior vena cava (IVC) filter placement might be ordered (ATI Nursing Education, 2011; Osborn et al., 2014). The |

|mortality rate for PE is heavily dependent on how severe the presentation is: “massive PE 50% versus nonmassive PE 8 -14%” (Domino, 2015). A risk assessment scale|

|called the simplified pulmonary embolism severity index (sPESI), which takes into account the severity of the acute PE event and the patient’s comorbidities, can |

|predict the prognosis of patient with an acute PE. It focuses on six main variables including an age greater than 80 years old, pulse greater than 100 beats per |

|minute, and history of cancer (Konstantinides & Goldhaber, 2012). |

( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]

|Name: apixaban (Eliquis) |Concentration (mg/ml) |Dosage Amount (mg): 10mg |

|Route: PO |Frequency: daily |

|Pharmaceutical class: factor xa inhibitors |Home Hospital or Both |

|Indication: decreases risk of stroke/systemic embolism associated with non-valvular atrial fibrillation |

|Side effects/Nursing considerations: bleeding, hypersensitivity including anaphylaxis; Do not discontinue abruptly—may increase risk of having a stroke; Inform |

|patient that they may bruise or bleed more easily/longer than usual—patient should notify HCP if signs of bleeding occur or if injury occurs |

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|Name: docusate-senna (Senokot S) |Concentration: |Dosage Amount: 1 tab (50 mg docusate sodium – 8.6 |

| | |mg sennosides) |

|Route: PO |Frequency: BID |

|Pharmaceutical class: stimulant laxatives; stool softeners |Home Hospital or Both |

|Indication: prevention of opioid-induced constipation |

|Side effects/Nursing considerations: electrolyte imbalances, dehydration, abdominal cramps, nausea, vomiting, diarrhea, rashes, urine discoloration; Laxatives |

|should only be used short-term (longer therapy may create an electrolyte imbalance and dependence); Instruct cardiac patients to avoid straining during bowel |

|movements; Encourage alternate forms of bowel regulation (e.g. increasing fluid intake). |

|Name: famotidine (Pepcid) |Concentration |Dosage Amount: 20 mg |

|Route: PO |Frequency: BID |

|Pharmaceutical class: histamine h2 antagonists |Home Hospital or Both |

|Indication: treatment of heartburn, acid indigestion, and sour stomach; management of GERD |

|Side effects/Nursing considerations: arrhythmias, agranulocytosis, aplastic anemia, hypersensitivity, constipation, diarrhea, nausea; Monitor CBC with differential|

|periodically during therapy; Give with meals or immediately afterward and at bedtime to prolong effect; Advise patient to avoid smoking and alcohol |

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|Name: hydrochlorothiazide (Microzide) |Concentration: |Dosage Amount: 12.5mg |

|Route: PO |Frequency: daily |

|Pharmaceutical class: thiazide diuretic |Home Hospital or Both |

|Indication: management of mild to moderate hypertension; treatment of edema |

|Side effects/Nursing considerations: dehydration, hypokalemia, hyponatremia, hypovolemia, hyperglycemia, hypotension,; Monitor patient’s potassium levels; Instruct|

|clients to take first thing in the morning; Obtain baseline data for patient (e.g. blood pressure, edema, weight, electrolytes); Monitor patient for increase in |

|blood glucose |

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|Name: losartan (Cozaar) |Concentration: |Dosage Amount: 100 mg |

|Route: PO |Frequency: daily |

|Pharmaceutical class: angiotensin II receptor antagonist |Home Hospital or Both |

|Indication: management of hypertension, stroke prevention |

|Side effects/Nursing considerations: angioedema, hyperkalemia, hypoglycemia, diarrhea; Observe for signs of angioedema (skin wheals, swelling of tongue); ARBs can |

|be taken with or without food; May have an additive effect with other hypertensives; Patient should avoid foods with high levels of K+ or salt substitutes; Advise |

|patient to avoid sudden changes in position |

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|Name: metoprolol |Concentration |Dosage Amount: 75 mg |

|Route: PO |Frequency: BID |

|Pharmaceutical class: beta blocker |Home Hospital or Both |

|Indication: primary hypertension, angina pectoris |

|Side effects/Nursing considerations: bradycardia, decreased cardiac output, rebound hypertension, orthostatic hypotension, erectile dysfunction, fatigue, weakness;|

|Do not discontinue abruptly; Monitor BP, ECG, and pulse frequently |

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|Name: oxybutynin (Ditropan XL) |Concentration |Dosage Amount: 5 mg |

|Route: PO |Frequency: BID |

|Pharmaceutical class: anticholinergic |Home Hospital or Both |

|Indication: overactive bladder (neurogenic bladder) |

|Side effects/Nursing considerations: angioedema, anaphylaxis, anticholinergic effects (e.g. constipation, dry mouth, etc.), CNS effects (e.g. hallucinations, |

|confusion, etc.); Monitor voiding pattern and intake/output ratios; Asses abdomen for bladder distension before and during therapy; Advise patient to avoid alcohol|

|and other CNS depressants |

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|Name: acetaminophen (Tylenol) |Concentration |Dosage Amount: 650 mg |

|Route: PO |Frequency: Q4H, PRN (for temperature) |

|Pharmaceutical class: antipyretic/ nonopioid analgesic |Home Hospital or Both |

|Indication: treatment of fever |

|Side effects/Nursing considerations: rash, uticaria, hepatoxicity at high doses; renal failure with high doses and chronic use; acute generalized exanthematous |

|pustulosis, Stevens-Johnson syndrome, toxic epidermal necrosis; Use medication as prescribed and do not exceed 4 g/day; Acetaminophen should not be taken longer |

|than 10 days unless directed by a HCP; Advise patient to avoid alcohol if taking more than an occasional 1 -2 doses; Discontinue use if rash occurs |

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|Name: hydromorphone (Dilaudid) |Concentration: |Dosage Amount: 1 mg |

|Route: PO |Frequency:Q4H, PRN (for severe pain 7-10) |

|Pharmaceutical class: opioid agonist |Home Hospital or Both |

|Indication: moderate to severe pain relief |

|Side effects/Nursing considerations: respiratory depression, constipation, orthostatic hypotension, urinary retention, cough suppression, sedation, |

|nausea/vomiting, dependence, tolerance, miosis; Monitor patient’s vital signs and stop opioid if respiratory rate < 12/min; Have naxolone available as an antidote;|

|Monitor I&O; Administer a stimulant laxative to avoid constipation; Do not discontinue the medication abruptly if dependence has been established |

|Name: hydrochlorothiazide-valsartan (Diovan HCT) |Concentration: |Dosage Amount: 12.5 mg hydrochlorothiazide – 160 mg|

| | |valsartan |

|Route: PO |Frequency: daily |

|Pharmaceutical class: angiotensin II receptor blocker/ diuretic |Home Hospital or Both |

|Indication: treatment for hypertension |

|Side effects/Nursing considerations: hypotension, hyperkalemia, hyponatremia, hypoglycemia, angioedema; Observe for signs of angioedema (skin wheals, swelling of |

|tongue); ARBs can be taken with or without food; May have an additive effect with other hypertensives; Patient should avoid foods with high levels of K+ or salt |

|substitutes; Advise patient to avoid sudden changes in position ; Obtain baseline data for patient (e.g. blood pressure, edema, weight, electrolytes); Monitor |

|blood glucose level |

|Name: |Concentration: |Dosage Amount: |

|Route: |Frequency: |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

|Name: |Concentration: |Dosage Amount: |

|Route: |Frequency: |

|Pharmaceutical class |Home Hospital or Both |

|Indication |

|Side effects/Nursing considerations |

|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |

|Diet ordered in hospital? Regular |Analysis of home diet (Compare to “My Plate” and |

|Diet pt follows at home? Weight-Watchers |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: |[pic] |

|Breakfast: 2 coffee (decaf, 6 oz. each), egg substitute, 2 pieces of wheat toast|[pic] |

| |[pic] |

|Lunch: ham & cheese sandwich (with wheat bread), 1 banana, 8 oz. water |As the graph illustrates, D.W.R. is eating the appropriate amount of proteins, |

| |but she needs to increase her intake of vegetables, whole fruit, dairy, and |

| |grains (whole and refined). It’s great that she’s consuming an adequate amount |

| |of protein given that she is recovering from a total knee replacement |

| |surgery—protein will help promote tissue growth and wound healing. However, I |

| |would recommend that she eat more vegetables such as broccoli or carrots, and |

| |dairy products such as milk, cheese etc. Eating foods in the dairy group can |

| |increase her calcium levels, improve her bone health, and help lower her blood |

| |pressure; foods in the vegetables group may help with her obesity as well reduce |

| |the risk of heart disease. As a side note, I would caution against the |

| |consumption of large amounts of vitamin K laden foods in the event she is given |

| |warfarin for anticoagulation. Lastly, I would suggest D.W.R. watch her sodium |

| |intake especially because of her history of hypertension. She’s over her limit |

| |by 530 milligrams (mg). |

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|Dinner: meat (1 chicken breast) + 1 cup of vegetables (1 sweet potato) + salad | |

|with low-fat ranch dressing | |

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|Snacks: Weight watcher snack (yogurt) + fruit (cantaloupe) | |

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|Liquids (include alcohol): Does not drink alcohol regularly | |

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|[pic] |Use this link for the nutritional analysis by comparing the patients 24 HR |

| |average home diet to the recommended portions, and use “My Plate” as reference. |

|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? My husband. |

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|How do you generally cope with stress? or What do you do when you are upset? |

|She finds relaxation through sewing. |

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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |

|She expressed that she sometimes has feelings of anxiety and being overwhelmed due to her ongoing issues with arthritis and her knee pain. |

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|+2 DOMESTIC VIOLENCE ASSESSMENT |

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|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |

|am going to ask some questions that help me to make sure that you are safe.” |

|Have you ever felt unsafe in a close relationship? No |

|Have you ever been talked down to? Yes Have you ever been hit punched or slapped?  No |

|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?  Yes If yes, have you sought help for this?  No |

|Are you currently in a safe relationship? Yes |

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|( 4 DEVELOPMENTAL CONSIDERATIONS: |

|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |

|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair |

|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your patient’s age group: |

|Given that D.W.R. is 74 years old, she falls under Erickson’s developmental stage 8: ego integrity versus despair (Treas & Wilkinson, 2014). An adult with ego |

|integrity is characterized as having a feeling of satisfaction for their life and an acceptance of their place in the circle of life. Alternatively, a despairing |

|adult is afraid of death and feels uncomfortable with the aging process. |

|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |

|D.W. R. displays more signs of despair than ego integrity. She appeared anxious over her current weight (“I mean look at me”) and her inability to be as active as|

|she would like to (“I was very athletic”; “I would love to get on a boat again”). Several times during our interview she mentioned her age (“I’m 74 years old”), |

|which leads to me believe that she is preoccupied with her old age and may view it negatively. |

|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |

|My patient has suffered from chronic arthritis for years and she stated that it “interrupts her lifestyle.” D.W.R.’s chronic joint pain and limited mobility could|

|have certainly made her feel generally unsatisfied with her life. Also, with her strong desire to be more active and more involved with hobbies she loves (e.g. |

|boating) it is highly likely that she is more unaccepting of her life and the aging process. |

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|+3 CULTURAL ASSESSMENT: |

|What do you think is the cause of your illness? |

| “[My] arthritis and being overweight. I mean, look at me.” |

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|What does your illness mean to you? |

|My patient indicated that her arthritis (especially her knees) “interrupts her lifestyle.” She stated that she is unable to do things the she wants, which |

|includes getting on a boat. She desires to one day be able to ride the boat that she helped her son buy. |

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|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |

|Consider beginning with:  “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |

|usually related to either infection, changes with aging and/or quality of life.  All of these questions are confidential and protected in your medical record” |

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|Have you ever been sexually active?___yes______________________________________________________________ |

|Do you prefer women, men or both genders? ___men_____________________________________________________ |

|Are you aware of ever having a sexually transmitted infection? ___no_________________________________________ |

|Have you or a partner ever had an abnormal pap smear? ___________no___________________________________ Have you or your partner received the Gardasil (HPV) |

|vaccination? _____no, no_________________________________ |

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|Are you currently sexually active?   _______yes_________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted |

|disease or an unintended pregnancy?  __”old age”, “monogamy”_______ |

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|How long have you been with your current partner?________50 years______________________________________ |

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|Have any medical or surgical conditions changed your ability to have sexual activity?  ________arthritis______________ |

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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? No |

±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?

_____Religion plays a fairly important role in her life_____________________

Do your religious beliefs influence your current condition?

___They have no significant influence.___________________________________

|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? X Yes No |

| If so, what? cigarettes |How much?(specify daily amount) |For how many years? 3 years |

| |1 pack per day |(age 18 thru 22 ) |

| | | |

|Pack Years: 3 | |If applicable, when did the patient quit? |

| | |During her college years (somewhere between |

| | |the ages of 18 and 22) |

| | | |

|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? Yes |

|No | |

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|2. Does the patient drink alcohol or has he/she ever drank alcohol? X Yes No |

| What? Gin and tonic, wine |How much? (give specific volume) |For how many years? Since childhood; home |

| | |remedy was to give a small amount of wine to |

| | |children in order to stimulate their appetites|

| |1 – 2 drinks per month (4 oz. each) |(age: childhood thru 74 ) |

| |Total = 240 mL | |

| | | |

| If applicable, when did the patient quit? | | |

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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |

| If so, what? |

| |How much? |For how many years? |

| | |(age thru ) |

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| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |

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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |

|No |

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( 10 Review of Systems

|General Constitution |Gastrointestinal |Immunologic |

| Recent weight loss or gain | Nausea, vomiting, or diarrhea | Chills with severe shaking |

|Integumentary | Constipation Irritable Bowel | Night sweats |

| Changes in appearance of skin – bruising from old IV | GERD Cholecystitis | Fever |

|sites | | |

| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |

| Dandruff | Hemorrhoids Blood in the stool | Lupus |

| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |

| Hives or rashes (under breasts and stomach) | Pancreatitis | Sarcoidosis |

| Skin infections | Colitis | Tumor |

| Use of sunscreen SPF: 15 - 30 | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: daily |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing |Genitourinary | Anemia |

| Cataracts or Glaucoma - developing | nocturia | Bleeds easily |

| Difficulty hearing | dysuria | Bruises easily |

| Ear infections | hematuria | Cancer |

| Sinus pain or infections | polyuria | Blood Transfusions |

|Nose bleeds | kidney stones |Blood type if known: A + |

| Post-nasal drip |Normal frequency of urination: 6x/day |Other: Chronic lymphatic leukemia (dx: 3 – 4 years |

| | |ago) |

| Oral/pharyngeal infection | Bladder or kidney infections | |

| Dental problems | |Metabolic/Endocrine |

| Routine brushing of teeth 2x/day | | Diabetes Type: |

| Routine dentist visits 1-2x/year | | Hypothyroid /Hyperthyroid |

|Vision screening | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

| | |Other: |

|Pulmonary | | |

| Difficulty Breathing | |Central Nervous System |

| Cough - dry or productive |Women Only | CVA |

| Asthma | Infection of the female genitalia | Dizziness |

| Bronchitis | Monthly self-breast exam - no | Severe Headaches |

| Emphysema | Frequency of pap/pelvic exam | Migraines |

| Pneumonia | Date of last gyn exam? Early this year (2015) | Seizures |

| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |

| Environmental allergies - pollen | menarche age? | Encephalitis |

|last CXR? In hospital | menopause age? Late 50s (~58) | Meningitis |

|X Other: Sleep apnea |Date of last Mammogram &Result: this year, good |Other: |

| |Date of DEXA Bone Density & Result: 6 –7 months , | |

| |unremarkable | |

|Cardiovascular |Men Only |Mental Illness |

|Hypertension | Infection of male genitalia/prostate? | Depression |

| Hyperlipidemia | Frequency of prostate exam? | Schizophrenia |

| Chest pain / Angina | Date of last prostate exam? | Anxiety |

|Myocardial Infarction | BPH | Bipolar |

| CAD/PVD |Urinary Retention |Other: |

|CHF |Musculoskeletal | |

|Murmur | Injuries or Fractures |Childhood Diseases |

| Thrombus | Weakness | Measles |

|Rheumatic Fever | Pain | Mumps |

| Myocarditis | Gout | Polio |

| Arrhythmias | Osteomyelitis | Scarlet Fever |

| Last EKG screening, when? 08/28/15 |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

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|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |

|None |

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|Any other questions or comments that your patient would like you to know? |

|None |

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|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |

|General Survey: Patient is well developed|Height: 63 inches |Weight: 110 kg BMI: 41.9 |Pain: (include rating & location) |

|74 year old women who is obese with no | | |9/10 in left knee |

|visible signs of acute distress. She is | | | |

|alert and oriented X3. | | | |

| |Pulse: 68 |Blood | |

| | |Pressure: 103/33 (right arm) | |

| | |(include location) | |

|Temperature: (route taken?) |Respirations: 20 | | |

|97.7, oral | | | |

| |SpO2: 98% |Is the patient on Room Air or O2: room air |

|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |

| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |

|Patient’s appearance is within normal limits except for an obvious handicap with her left knee. She has a bandaged left knee from surgery. |

| |

|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |

| awake, calm, relaxed, interacts well with others, judgment intact |

| |

|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |

| clear, crisp diction |

| |

|Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat |

| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |

|Other: |

|Integumentary | |

| Skin is warm, dry, and intact | |

| Skin turgor elastic | |

| No rashes, lesions, or deformities | |

| Nails without clubbing | |

| Capillary refill < 3 seconds | |

| Hair evenly distributed, clean, without vermin | |

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|Incision on left knee | |

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| Peripheral IV site Type: 20 gauge Location: left antecubital Date inserted: |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

| Peripheral IV site Type: 22 gauge Location: right hand Date inserted: |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

| Central access device Type: Location: Date inserted: |

|Fluids infusing? no yes - what? |

| |

|HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline |

| Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge |

| Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |

| PERRLA pupil size / 3 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |

| Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches |

| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |

|Dentition: permanent bridge, top left, |

|Comments: Did not initiate a whisper test; patient responds appropriately to verbal commands |

| |

|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |

| | | Lungs clear to auscultation in all fields without adventitious sounds |

| |CL – Clear |Percussion resonant throughout all lung fields, dull towards posterior bases |

| |WH – Wheezes |Sputum production: thick thin Amount: scant small moderate large |

| |CR - Crackles | Color: white pale yellow yellow dark yellow green gray light tan brown red |

| |RH – Rhonchi | |

| |D – Diminished |No sputum production, percussion not assessed |

| |S – Stridor | |

| |Ab - Absent | |

| | | |

| | | |

|Cardiovascular: No lifts, heaves, or thrills PMI felt at: 5th ICS, midclavicular line |

|Heart sounds: S1 S2 Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |

|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |

|[pic] |

| Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |

|Apical pulse: Carotid: Brachial: Radial: +2 Femoral: Popliteal: DP: +2 PT: |

|No temporal or carotid bruits Edema: +1 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |

|Location of edema: left thigh pitting non-pitting |

|Extremities warm with capillary refill less than 3 seconds |

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| |

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| |

| |

|GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |

|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation |

|Urine output: Clear Cloudy Color: Previous 24 hour output: mLs N/A |

|Foley Catheter Bedside Commode Bathroom Privileges without assistance or with assistance |

|CVA punch without rebound tenderness |

|Last BM: (date 09 / 04 / 15 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |

|Hemoccult positive / negative (leave blank if not done) |

|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |

| Other – Describe: |

| |

| |

|Musculoskeletal: ( Full ROM intact in all extremities without crepitus |

|Strength bilaterally equal at _5__ RUE ___5____ LUE ____5___ RLE & __4_____ in LLE |

|[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] |

|vertebral column without kyphosis or scoliosis |

|Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias |

|Pain and decreased range of motion in left knee – 5/5 strength in BUE, 4/5 in RLE, 3-4/5 in LUE |

| |

| |

|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |

|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |

|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride |

|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |

|Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: |

|positive negative |

|Patient had difficulty getting in and out of bed as well as to and from the bedside commode. Gait was slow and heavily favored the right leg/foot. |

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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |

|diagnostic tests): |

|Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need prior to and after surgery, and pertinent to |

|hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that |

|is done preop) then include why you expect it to be done and what results you expect to see. |

| |

|Lab |

|09/02/2015 |

|09/01/2015 |

|Trend |

|Analysis |

| |

|WBC |

|4.5 – 11 (x 103/µL) |

| |

|17.6 H |

|20.8 H |

|White blood cells (WBCs) were high but are trending down. |

|WBCs are the body’s main defense system against foreign organisms/substances. A high WBC may be indicative of an inflammation/ infectious response. My patient did |

|recently have a total left knee replacement (08/27/2015) |

| |

|RBC |

|3.71 – 5.31 million/µL |

|3.66 L |

|3.71L |

|Red blood cells (RBCs) were low and are trending down. |

|RBC transport and exchange oxygen (O2) to the tissues. Low levels may be contributed to leukemia (the patient has a history of chronic lymphocytic leukemia [CLL]). |

| |

|Hgb |

|11.7 – 16.1 g/dL |

|10.8 L |

|10.8 L |

|Hemoglobin (Hgb) was low and is trending low. |

|Hgb carries O2 to and take away CO2 from RBCs. Low Hgb may be indicative of the patient’s CLL and recent surgery. |

| |

|Hct |

|34 – 46% |

|32.5 L |

|32.7 L |

|Hematocrit (Hct) was low and is trending down. |

|Hct is the number of RBCs expressed as a percentage of whole blood. Low Hct may be indicative of the patient’s CLL and recent surgery. |

| |

|Platelet count |

|150 – 450 (x 103/µL) |

|237 |

|220 |

|Platelet count is within normal limits (WNL). |

| |

| |

|Sodium |

|135 – 145 mEq/L |

|134 L |

|133 L |

|Sodium was low but trending up. |

|Sodium is the major extracellular cation and has several functions. Low sodium may indicate poor intake, hypoproteinemia, and/or excessive use of diuretics. D.W.R.|

|was urinating very frequently and is taking a diuretic (Microzide) |

| |

|Potassium |

|3.5 – 5 mEq/L |

|4.4 |

|4.6 |

|Potassium is WNL. |

| |

| |

|Chloride |

|95 – 105 mEq/L |

|99 |

|98 |

|Chloride is WNL. |

| |

| |

|CO2 |

|23 – 29 mEq/L |

|28.8 |

|27 |

|Bicarbonate (serum CO2) is WNL. |

| |

| |

|Glucose |

|70 – 110 mg/dL |

|117 H |

|140 H |

|Glucose was high but is trending down. |

|A high glucose may be related to an acute stress reaction (patient is in pain from knee), |

| |

|BUN |

|8 – 21 mg/dL |

|8 |

|14 |

|Blood urea nitrogen (BUN) is WNL. |

| |

| |

|Creatinine |

|0.51 – 1.11 mg/dL |

|0.5 L |

|0.6 |

|Creatine started off normal but is now trending slightly down. |

|Creatine is an indicator of renal function. The Cr level is only slightly lowered but it may indicate some decreased muscle mass or muscular dystrophy. Pt does |

|have some mobility issues given the injured knee. |

| |

|Osmo calc |

|275 – 295 mOsm/kg |

|268 L |

| |

|Osmolality is low. Trend not available. |

|Osmolality is the number of particles in a solution. Low osmo may be related to hyponatremia. |

| |

|Albumin |

|3.2 – 4.6 g/dL |

|2.7 L |

| |

|Albumin is low. Trend not available. |

|Albumin is the major protein in the body. Low albumin can indication insufficient protein intake and prolonged immobilization, |

| |

|CK MB |

|0 – 4% |

|2.7 |

|3.4 |

|Creatinine kinase (CK-MB) is WNL. |

| |

| |

|CPK Total |

|36 – 160 units/L |

|460 H |

|*557 C |

|Creatine phosphokinase (CPK) was at a critical level upon admission and is still high. However, it is trending down. |

|CK is released when skeletal and cardiac muscle (sometimes the brain and lungs too) tissue are injured. High total CK is related to surgery/trauma, muscular |

|dystrophy, PE, and loss of blood supply to muscle. |

| |

|LDL |

|(optimal: 60 mg/dL; acceptable: 40 – 60 mg/dL |

|48 |

| |

|HDL is WNL |

| |

| |

|Triglyceride |

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