UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Ashley Hale |

|MSI & MSII Patient Assessment Tool . |Assignment Date: 3/4/2016 |

| ( 1 PATIENT INFORMATION |Agency: MPM |

|Patient Initials: D.M. |Age: 68 |Admission Date: 3/2/2016 |

|Gender: Male |Marital Status: Married |Primary Medical Diagnosis: |

|Primary Language: English |Coronary artery disease |

| |ICD-10 Code: I25.110 (Centers for Medicare & Medicaid Services) |

|Level of Education: College Graduate – Bachelor’s |Other Medical Diagnoses: (new on this admission) |

|Occupation: General contractor |Patient was unaware of any new diagnoses |

|Number/ages children/siblings: 1 living brother (58 years old), 1 living sister (73 years | |

|old), 1 daughter (40 years old), 1 son (36 years old) | |

|Served/Veteran: Army |Code Status: Full Code |

|If yes: Ever deployed? Yes or No | |

|Living Arrangements: Patient reports living in a two floor house with wife. |Advanced Directives: Will |

| |If no, do they want to fill them out? N/A |

|Culture/ Ethnicity /Nationality: White/ Non-Hispanic |Surgery Date: 3/2/2016 Procedure: Stent placement |

|Religion: Christian |Type of Insurance: Medicare |

|( 1 CHIEF COMPLAINT: The patient reports coming to the hospital “for a stent placement that they said I |

|needed the last time I came in.” Patient reports arriving at the hospital with “dull and consistent” chest pain that was a 6 |

|on a pain scale of 1-10. The patient now reports no pain. |

| |

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

|This patient was previously brought into Morton Plant Mease Hospital on January 15, 2016 for a heart catheterization that |

|revealed a 90% blockage of the left anterior descending (LAD) artery of the heart. It was determined that the patient |

|needed a stent placed. For reasons not indicated in the chart, the patient did not have the procedure done until March 2, |

|2016. Before the procedure a pre-intervention angiography was performed to determine the sites of occlusion where the |

|percutaneous coronary intervention would be performed. After the procedure the patient was admitted from the |

|catheterization lab. Before surgery the patient reports having a “constant dull, aching pain” in his chest that began in |

|October. This pain was relieved with sitting forward and increased with laying down, after eating, and during strenuous |

|activity. The patient is now two days post-cath and reports no current chest or other pain. This patient has a history of |

|coronary artery disease, hypertension, hyperlipidemia, type II diabetes mellitus, and osteoarthritis. The patient is now |

|on Witt 4 while on aspirin (PO), atenolol (PO), atorvastatin (PO), and lisinopril (PO). |

| |

( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of disease

|Date |Operation or Illness |

|2002 |Lumbar discectomy |

|2003 |Liver biopsy – results not available |

|9/4/2003 |Colonoscopy - insignificant |

|4/27/2012 |Colonoscopy – colon polyps (removed) |

|1/15/2016 |Cardiac catheterization with a diagnosis of coronary artery disease |

| | |

| | |

|( 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) Is within 10 years? “Yes” | | |

|Influenza (flu) (Date) Is within 1 years? “Yes” | | |

|Pneumococcal (pneumonia) (Date) Is within 5 years? “Yes” | | |

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

If yes: give date, can state “U” for the patient not knowing date received

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

|REACTIONS |Causative Agent | |

|Medications | | |

| | | |

| | |No known medication allergies |

| | | |

| | | |

| | | |

|Other (food, tape, latex, dye, | | |

|etc.) | | |

| | |No known food, tape, latex, dye, or environmental allergies |

| | | |

| | | |

|( 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) |

|This patient has been diagnosed with coronary artery disease, which is most likely caused by lifestyle choices and other medical diagnoses. There are two main |

|arteries that supply the heart with the blood and oxygen it needs to function properly. Coronary artery disease is “ a progressive atherosclerotic disorder…that |

|results in narrowing or complete occlusion of the vessel lumen.” (Osbourn, Wraa, Watson, & Holleran, 2014) This can be extremely harmful to the patient because if |

|the vessel becomes too blocked, blood will no longer be able to flow to the cardiac tissue. If this happens the patient can experience chest pain, heart attack and |

|even death. This patient had occlusion of the left anterior descending (LAD) artery, this artery is especially important because it supplies the left ventricle, |

|which is responsible for pumping blood to supply the entire body. If blood flow cannot be established and the left ventricle is unable to function properly, this |

|could result in decreased tissue perfusion that could cause permanent damage and death. This blockage is most likely cause by the patient’s hyperlipidemia, which |

|can cause a build up of lipids and plaque in the arteries. The patient also has other predisposing factors that include obesity, high blood pressure, and diabetes.|

|This disease is diagnosed with a cardiac catheterization. For this procedure an incision is made in the patient’s groin and a catheter is used to inject dye into |

|the vessels of the heart. By observing this dye it is clear to see where a person may have partial blockages or occlusions of the vessels of the heart. When |

|blockage is found, a typical treatment is to place a stent in the vessel that is occluded. This stent is a mechanism that expands to open the walls of the vessel |

|to allow blood flow. Placement of a stent is followed with antiplatelet therapy, this is used to help thin the blood to allow for better movement through the |

|vessels. As well as to prevent clots from forming on the stent. This patient is now receiving aspirin PO and ticagrelor for antiplatelet therapy, atenolol and |

|lisinopril (Zestril) for hypertension, and atorvastatin (Lipitor) for hyperlipidemia. |

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

|Name aspirin |Concentration 81mg |Dosage Amount 81 mg |

|Route PO |Frequency once daily |

|Pharmaceutical class salicylates |Home Hospital or Both |

|Indication Prophylaxis of MI, antiplatelet therapy |

|Adverse/ Side effects This medication can cause tinnitus, epigastric distress, nausea, hepatotoxicity, anemia, rash, and urticarial. It can also cause |

|life-threatening reactions such as GI bleeding, anaphylaxis and laryngeal edema. |

|Nursing considerations/ Patient Teaching The nurse should not give this drug to patient’s who have an allergy to it. They should also monitor the patient for side|

|effects that could indicate toxicity. The nurse should teach the patient to take with a full glass of water to avoid gastric upset and to avoid alcohol to |

|decrease the risk of GI bleeding. Also instruct the patient to notify the provider of any adverse effects. |

|Name atenolol |Concentration 25mg |Dosage Amount 12.5 mg |

|Route PO |Frequency once daily |

|Pharmaceutical class Beta-blocker |Home Hospital or Both |

|Indication Hypertension |

|Adverse/ Side effects This medication commonly causes fatigue, weakness, and erectile dysfunction. It can also cause dizziness, drowsiness, constipation, nausea,|

|and vomiting. Some adverse effects are bradycardia, heart failure, and pulmonary edema. |

|Nursing considerations/ Patient Teaching Teach the patient to take this medication at the same time every day and be sure not to skip doses. Teach the patient how |

|to take their own blood pressure and have them check it daily and report changes. Also instruct the pt to change positions slowly to avoid orthostatic |

|hypotension. Also instruct the patient to report any signs of adverse effects such as slow heart rate, difficulty breathing, and rash. The nurse should be sure to |

|check heart rate and blood pressure before and after medication is given. |

|Name atorvastatin (Lipitor) |Concentration 40mg |Dosage Amount 40mg |

|Route PO |Frequency once daily |

|Pharmaceutical class HMG-CoA reductase inhibitor |Home Hospital or Both |

|Indication Hyperlipidemia |

|Adverse/ Side effects Some side effects of this drug are headache, insomnia, bronchitis, chest pain, and hyperglycemia. It most frequently causes abdominal |

|cramps, constipation, diarrhea, flatus, heartburn, and rashes. Its most adverse effect if the cause of rhabdomyolysis. |

|Nursing considerations/ Patient Teaching Teach the patient to take the medications as directed as well as with the recommended diet of low fat, carbohydrates, and|

|alcohol. Patient should notify the provider if they experience any muscle weakness or pain, as this could be a sign of developing rhabdomyolysis. |

|Name insulin (NovoLOG) |Concentration 1 unit/0.01 mL |Dosage Amount sliding scale |

|Route Subcutaneous Injection |Frequency 3x daily |

|Pharmaceutical class pancreatics |Home Hospital or Both |

|Indication Diabetes Mellitus Type II |

|Adverse/ Side effects Some side effects are hyperkalemia, pruritis, and swelling. Two adverse effects of this medication are hypoglycemia and anaphylaxis. |

|Nursing considerations/ Patient Teaching Ensure the patient is able to check their blood sugar, determine the amount of insulin needed according to the sliding |

|scale, and administer the medication to themselves. Explain the signs and symptoms of hypoglycemia and teach them how to manage it as well as instruct them to |

|notify their provider for symptoms of an anaphylactic response. |

|Name isosorbide mononitrate |Concentration 30mg |Dosage Amount 1 tab |

|Route PO |Frequency once daily |

|Pharmaceutical class nitrates |Home Hospital or Both |

|Indication angina |

|Adverse/ Side effects Common side effects are dizziness, headache, hypotension, and tachycardia. Other side effects include bradycardia, nausea, and vomiting. |

|Nursing considerations/ Patient Teaching Because this medication can cause dizziness and hypotension it is important to instruct the patient to change positions |

|slowly to avoid dizziness and orthostatic hypotension. Instruct the patient to take the medication as directed. Also ensure the patient that headache is a common |

|side effect and should decrease with continued treatment. |

|Name linsinopril (Zestril) |Concentration 10mg |Dosage Amount 10 mg |

|Route PO |Frequency once daily |

|Pharmaceutical class ACE inhibitor |Home Hospital or Both |

|Indication Hypertension |

|Adverse/ Side effects Common side effects are dizziness, cough, and hypotension. Other side effects are fatigue, headache, nausea, vomiting, hypoglycemia and |

|hyperkalemia. One adverse effect is angioedema. |

|Nursing considerations/ Patient Teaching Teach the patient to avoid salt substitutes containing potassium and foods that contain high potassium. Because this |

|medication can cause hypoglycemia it is important for the patient to closely monitor their blood glucose levels. Instruct the patient to report any rashes, sores, |

|chest pain, or dry cough to their health care provider. |

|Name ticagrelor |Concentration 90mg |Dosage Amount 90mg |

|Route PO |Frequency twice daily |

|Pharmaceutical class Platelet aggregation inhibitor |Home Hospital or Both |

|Indication prophylaxis for stent thrombosis |

|Adverse/ Side effects A common side effect is dyspnea. Other side effects can include bradycardia and gynecomastia. Adverse effects are bleeding and angioedema. |

|Nursing considerations/ Patient Teaching Teach the patient that bleeding and bruising will be more common and bleeding will be harder to stop. Advise patient to |

|not exceed more than 100mg of aspirin per day because this will increase bleeding risk. Also advise the patient to notify theer health care provider of any |

|adverse effects. |

|Name Nitroglycerin (Nitrostat) |Concentration 0.4mg |Dosage Amount 0.4mg |

|Route sublingual |Frequency PRN (1 tab q4hr for 3 tabs) |

|Pharmaceutical class nitrates |Home Hospital or Both |

|Indication Chest Pain |

|Adverse/ Side effects Common side effects are headache, dizziness, hypotension, and tachycardia. Other side effects are blurred vision, abdominal pain, nausea, and|

|vomiting. |

|Nursing considerations/ Patient Teaching Inform patient that headaches are common and should decrease with use. Instruct the patient to take this medication only |

|when necessary. This medication should be given five minutes apart, up to three doses if pain does not decrease or go away completely notify the provider. |

(Unbound Medicine)

[pic]

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

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

|Diet patient follows at home? |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: | |

|Breakfast: 2 eggs (scrambled) with salt and pepper, potatoes (2 cups) with salt, |Based on the patient’s 24-hour diet recall, there are many changes that could be |

|pepper, and onions, and white toast (1 slice) with butter, coffee – 2 servings of|made to improve the patient’s health. First, the patient has no fruit reported in|

|(8oz) with half and half (2 small containers), and sugar (3 packets) |their diet at all. Fruits are imperative in a diet because they provide |

|Lunch: Sandwich – 2 slices white bread, 2 slices ham, 2 slices American cheese, |essential nutrients that help the body function properly. Fruits are also an |

|mustard (2 packets), potato chips (1 serving), diet pepsi (32 oz.) |important source of fiber, which is needed to help with gastric motility. I would|

| |suggest adding whole, |

|Dinner: Spaghetti (2 cups), meatballs – ground beef (4 large meatballs), tomato |fresh fruit such as bananas or strawberries as a snack. Next, the patient is not |

|sauce (1 cup) Garlic bread (2 pieces), water (16 oz.) |receiving an adequate amount of dairy. Dairy contains calcium which is necessary|

| |for bone |

|Snacks: Ice cream (1 scoop) |strength and cardiac muscle function, because this patient |

|Liquids (include alcohol): Coffee (16 oz.), Water (16 oz.), diet pepsi (32 oz.) |has cardiovascular problems it will be important for him to maintain cardiac |

| |health. To do this I would suggest replacing a glass of soda with a glass of |

| |milk, or having a cup of yogurt with breakfast. Although the patient has more |

| |than the recommended amount of vegetables in their diet, both forms, the potatoes|

| |and tomato sauce both contain increased amounts of sodium. Using low sodium |

| |products or making sauce from scratch could provide a much healthier way of |

| |eating the same foods. Grains are another important aspect of a well balanced |

| |diet, and although the patient exceeds the recommended amount, they are only |

| |eating refined grains. A better option would be to switch to whole grains or |

| |multi-grains. All of the grain products the patient is using, such as bread and |

| |spaghetti are available in whole grain or multigrain options, usually for the |

| |same price! The patient also needs to decrease the amount of sodium in their |

| |diet. Sodium can cause an increase in fluid retention, because the patient has |

| |cardiac problems, this could put them at higher risk for heart failure. To |

| |decrease sodium the patient should switch to low sodium products and avoid adding|

| |salt to meals. The patient also has an increased amount of saturated fat. This |

| |is important because the patient currently has hyperlipidemia and coronary artery|

| |disease, having increased fat in the diet could make these diseases worse. |

| |Cutting out soda and eating more, fresh and natural foods would benefit the |

| |patient by decreasing fat, sodium, and total calories. I would also recommend |

| |the patient stay away from fried and processed foods. This could help the |

| |patient lose weight and improve their overall health. |

|[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 a reference.|

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

|Who helps you when you are ill? “When I get sick my wife will take care of me.” |

| |

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

|“I usually cope with stress fairly well.” “I like to go play poker.” |

| |

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

|“I have a lot of stress from my work, it’s a lot of stress on my body and makes me really tired.” |

| |

| |

|+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? “No”___________ 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?  |

|“No”____________________________________ If yes, have you sought help for this?  N/A____________________ |

| |

|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: According to the text, the stage of Ego Integrity vs. Despair is related to how the person views their past and how they feel about the life |

|that they have lived. If a person has ego integrity they are generally happy with how their life has been and they feel that they have been beneficial to society. |

|They more comfortable with death being the next phase. A person is categorized as being in despair if they see their life as having been insignificant and they |

|are more afraid of death. (Treas & Wilkinson 2014) |

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

|This patient would be considered having ego integrity rather than despair because the patient has children and grandchildren that he still keeps in touch with and |

|is an active part of their lives. This patient is also an active part of the community and still works as a general contractor. This patient was pleasant and had|

|a positive view of the past and future. |

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

|This condition has made it difficult for the patient to perform physical activities without any pain. This has affected the patient’s ability to work. He hopes |

|that with the placement of the stent his chest pain will decrease and he will be able to do his job more efficiently and be able to do more activities with his |

|grandchildren. |

|+3 CULTURAL ASSESSMENT: |

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

|“I think it was caused by the crappy food I eat sometimes” |

| |

| |

|What does your illness mean to you? |

|“It means I need to change my lifestyle.” “I need to start eating better and exercising more.” |

| |

| |

|+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? “Women”_____________________________________________________ |

|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”_______________________________________ |

| |

|Are you currently sexually active?   “Yes”____________________ If yes, are you in a monogamous relationship? “Yes”______________ When sexually active, what |

|measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?  “None”_____________________________ |

| |

|How long have you been with your current partner? “43 years”______________________________________________ |

| |

|Have any medical or surgical conditions changed your ability to have sexual activity?  “No”________________________ |

| |

|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |

|“No, not anymore” |

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

What importance does religion or spirituality have in your life?

“Religion is very important in my life, I do go to church every week.”______________________________________________

Do your religious beliefs influence your current condition?

“No”____________________________________________________________________________________________________

______________________________________________________________________________________________________

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

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

| If so, what? |How much?(specify daily amount) |For how many years? N/A years |

| | |(age thru ) |

| | | |

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

| | | |

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

| |If yes, what did they use to try to quit? |

| |

| |

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

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

| |Volume: |(age thru ) |

| |Frequency: | |

| 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? |

|Marijuana |How much? |For how many years? 50 years |

| |1-2 times per week |(age 18 thru 68 ) |

| | | |

| 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” |

| |

| |

|5. For Veterans: Have you had any kind of service related exposure? |

|“No” |

| |

| |

| |

| |

( 10 Review of Systems Narrative

| |Gastrointestinal |Immunologic |

| | Nausea, vomiting, or diarrhea | Chills with severe shaking |

|Integumentary | Constipation Irritable Bowel | Night sweats |

| Changes in appearance of skin “with age” | GERD Cholecystitis | Fever |

| 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 | Pancreatitis | Sarcoidosis |

| Skin infections | Colitis | Tumor |

| Use of sunscreen “No” SPF: | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: “Once daily” |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing |Genitourinary | Anemia |

| Cataracts or Glaucoma “artificial lenses” | nocturia | Bleeds easily “from medication” |

| Difficulty hearing | dysuria | Bruises easily “from medication” |

| Ear infections | hematuria | Cancer |

| Sinus pain or infections | polyuria | Blood Transfusions |

|Nose bleeds | kidney stones |Blood type if known: Unknown |

| Post-nasal drip |Normal frequency of urination: 4 x/day |Other: |

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

| Dental problems | |Metabolic/Endocrine |

| Routine brushing of teeth 1 /day | | Diabetes Type: II |

| Routine dentist visits 1 /year | | Hypothyroid /Hyperthyroid |

|Vision screening “3 or 4 months ago” | | 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 | Severe Headaches |

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

| Pneumonia | Date of last gyn exam? | Seizures |

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

| Environmental allergies | menarche age? | Encephalitis |

|last CXR? “last time I came to the hospital” | menopause age? | Meningitis |

|Other: |Date of last Mammogram &Result: |Other: |

| |Date of DEXA Bone Density & Result: | |

|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? |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

| | | |

|General Constitution |

|Recent weight loss or gain |

|How many lbs? |

|Time frame? |

|Intentional? |

|How do you view your overall health? “Pretty good, other than my heart problems. But I could do better.” |

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

|“No” |

| |

| |

| |

| |

| |

| |

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

|“No” |

| |

| |

| |

| |

|±10 PHYSICAL EXAMINATION: |

| |

|General Survey: Patient is a healthy 68 y.o. male who is of normal height and mildly obese with no visible signs of distress and is alert and oriented times 3. |

|Height 68 inches |

|Weight 220 pounds |

|BMI 32.5 |

|Pain: (include rating and location) |

| |

|0/10 |

| |

| |

|Pulse 77 |

|Blood Pressure: (include location) |

| |

| |

|137/89 (left arm) |

| |

| |

| |

|Respirations |

| |

|17 |

| |

| |

| |

|Temperature: 98.7 degrees F (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 |

| |

| |

|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 |

| |

|Patient has a 22 gauge IV in the Left AC with no fluids infusing. There is no redness, edema, or discharge noted. |

| |

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

| Ears symmetric without lesions or discharge Whisper test heard: right ear- 8 inches & left ear- 8 inches |

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

|Dentition: |

|Comments: |

| |

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

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

|Sputum production: thick thin Amount: scant small moderate large |

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

|Lung sounds: Clear to bases |

|RUL CL LUL CL |

|RML CL LLL CL |

|RLL CL |

| |

|CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent |

|Cardiovascular: No lifts, heaves, or thrills |

| |

|Heart sounds: S1 S2 audible 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] |

|Normal Sinus Rhythm |

| |

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

| |

|Apical pulse: 2+ Carotid: 2+ Brachial: 2+ Radial: 2+ Femoral: could not find Popliteal: could not find DP: 2+ PT: could|

|not find |

| |

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

| |

|Location of edema: pitting non-pitting |

| |

|Extremities warm with capillary refill less than 3 seconds |

| |

| |

| |

|GI 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 |

| |

|Last BM: (date 3 / 4 / 2016 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

| |

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

| |

|Nausea emesis Describe if present: |

| |

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

| |

|Other – Describe: |

| |

| |

| |

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

| |

|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |

| |

|CVA punch without rebound tenderness |

| |

| |

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

| |

|Strength bilaterally equal at ___5___ RUE ___5____ LUE ___4____ RLE & ___5____ 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 paresthesia |

| |

| |

| |

|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: +2 Biceps: +2 Brachioradial: could not find Patellar: +2 Achilles: could not find Ankle clonus: positive |

|negative Babinski: positive negative |

| |

| |

| |

| |

| |

|±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 |

|Dates |

|Trend |

|Analysis |

| |

|HGB |

| |

| |

| |

|L 13.4 |

| |

| |

| |

| |

| |

|(Normal: 13.5 – 18 g/dL) |

| |

| |

| |

| |

|3/3/2016 |

|On admission this patient had a slightly low hemoglobin level. |

|Hemoglobin is a component of the blood that transports oxygen to the many tissues of the body. Low levels can cause decreased tissue perfusion and damage to the |

|tissues. Because the hemoglobin is only (.1) lower than the normal it is not critical, but this value should be monitored for any further decrease. |

| |

|HCT |

| |

| |

|L 39.4 |

| |

| |

| |

|(Normal: 39.5% - 51%) |

| |

| |

| |

|3/3/2016 |

|On admission, this patient had a slightly low hematocrit level. |

|Hematocrit is a level of the blood that indicates low red cell production. Extremely low levels of this can be indicative of anemia. This patient does not have |

|levels that would indicate anemia, but this level should also be closely monitored. |

| |

|Calcium |

| |

| |

| |

|L 8.2 |

| |

| |

|(Normal: 9 – 11 mg/dL) |

| |

| |

| |

| |

|3/3/2016 |

|On admission, this patient had a low calcium level. |

|Calcium is an important nutrient that is used for bone strength and cardiac muscle functioning. This patient should increase the amount of calcium in their diet to |

|ensure normal functioning and bone development. |

| |

|Troponins |

| |

| |

| |

|C* 3.660 |

| |

|C* 3.220 |

| |

| |

| |

| |

|(Normal: ................
................

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