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 | |
| | |
| | |
|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.” |
| |
| |
| |
|( 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). |
| |
|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. |
| |
( 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 |
| | |
|2002 |Right knee surgery; pain medication given for treatment along with rehabilitation |
| | |
|2000 |Orthoscopic surgery – clean up jagged bone from arthritis |
| | |
|1976 |Gallbladder removal (cholecystectomy) |
| | |
| | |
| | |
| | |
| | |
|( 2 FAMILY MEDICAL HISTORY |
| |
|( 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 | |
| | | |
| | | |
| | | |
| | | |
| | | |
|Other (food, tape, latex, dye, |None | |
|etc.) | | |
| | | |
| | | |
| | | |
|( 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). |
| |
|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). |
| |
|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). |
| |
|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 |
| |
| |
|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 |
| |
|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 |
| |
|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 |
| |
|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 |
| |
| |
|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 |
| |
|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 |
| |
|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). |
| | |
|Dinner: meat (1 chicken breast) + 1 cup of vegetables (1 sweet potato) + salad | |
|with low-fat ranch dressing | |
| | |
|Snacks: Weight watcher snack (yogurt) + fruit (cantaloupe) | |
| | |
|Liquids (include alcohol): Does not drink alcohol regularly | |
| | |
|[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. |
| |
|How do you generally cope with stress? or What do you do when you are upset? |
|She finds relaxation through sewing. |
| |
| |
| |
|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. |
| |
| |
| |
|+2 DOMESTIC VIOLENCE ASSESSMENT |
| |
|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 |
| |
| |
|( 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. |
| |
|+3 CULTURAL ASSESSMENT: |
|What do you think is the cause of your illness? |
| “[My] arthritis and being overweight. I mean, look at me.” |
| |
|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. |
| |
|+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” |
| |
|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_________________________________ |
| |
|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”_______ |
| |
|How long have you been with your current partner?________50 years______________________________________ |
| |
|Have any medical or surgical conditions changed your ability to have sexual activity? ________arthritis______________ |
| |
|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 | |
| |
| |
|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? | | |
| |
| |
|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 ) |
| | | |
| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |
| | | |
| | | |
|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |
|No |
| |
| |
| |
| |
| |
| |
| |
| |
( 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: |
| | | |
|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |
|None |
| |
| |
| |
| |
| |
| |
|Any other questions or comments that your patient would like you to know? |
|None |
| |
| |
| |
| |
|±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 | |
| | |
|Incision on left knee | |
| | |
| | |
| 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 |
| |
| |
| |
| |
| |
|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. |
| |
| |
| |
|±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 |
| ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- university of south florida hospital
- university of south florida map
- university of south florida campus map
- university of south florida college of medicine
- university of south florida medical school
- university of south florida majors
- university of south florida deadlines
- university of south florida programs
- university of south florida early action
- university of south florida requirements
- university of south florida admissions portal
- university of south florida application status