south nsg6440 week 3 discussion latest 2017 november

Name:

Pt.
Encounter Number:

Date:

Age:

Sex:

SUBJECTIVE

CC:

Reason
given by the patient for seeking medical care “in quotes”

HPI:

Describe
the course of the patient’s illness, including when it began, character of
symptoms, location where the symptoms began, aggravating or alleviating
factors, pertinent positives and negatives, other related diseases, past
illnesses, and surgeries or past diagnostic testing related to the present
illness.

Medications:
(List with reason for med )

PMH

Allergies:

Medication
Intolerances:

Chronic
Illnesses/Major traumas

Hospitalizations/Surgeries

“Have
you ever been told that you have diabetes, HTN, peptic ulcer disease,
asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems,
or psychiatric diagnosis?”

Family
History

Does
your mother, father, or siblings have any medical or psychiatric
illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN,
cancer, TB, DM, or kidney disease?

Social
History

Education
level, occupational history, current living situation/partner/marital status,
substance use/abuse, ETOH, tobacco, and marijuana. Safety status

ROS

General

Weight
change, fatigue, fever, chills, night sweats, and energy level

Cardiovascular

Chest
pain, palpitations, PND, orthopnea, and edema

Skin

Delayed
healing, rashes, bruising, bleeding or skin discolorations, and any changes
in lesions or moles

Respiratory

Cough,
wheezing, hemoptysis, dyspnea, pneumonia hx, and TB

Eyes

Corrective
lenses, blurring, and visual changes of any kind

Gastrointestinal

Abdominal
pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and
black, tarry stools

Ears

Ear
pain, hearing loss, ringing in ears, and discharge

Genitourinary/Gynecological

Urgency,
frequency burning, change in color of urine.

Contraception,
sexual activity, STDs

Female: last pap, breast, mammo, menstrual complaints, vaginal discharge,
pregnancy hx

Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat

Sinus
problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and
throat pain

Musculoskeletal

Back
pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis

Breast

SBE,
lumps, bumps, or changes

Neurological

Syncope,
seizures, transient paralysis, weakness, paresthesias, and black-out spells

Heme/Lymph/Endo

HIV
status, bruising, blood transfusion hx, night sweats, swollen glands,
increase thirst, increase hunger, and cold or heat intolerance

Psychiatric

Depression,
anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx

OBJECTIVE

Weight
BMI

Temp

BP

Height

Pulse

Resp

General
Appearance

Healthy-appearing
adult female in no acute distress. Alert and oriented; answers questions
appropriately. Slightly somber affect at first and then brighter later.

Skin

Skin
is brown, warm, dry, clean, and intact. No rashes or lesions noted.

HEENT

Head
is normocephalic, atraumatic, and without lesions; hair evenly distributed.
Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears:
Canals patent. Bilateral TMs pearly gray with positive light reflex;
landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No
septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no
occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist.
Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2
with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs.
Capillary refills two seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric
chest wall. Respirations regular and easy; lungs clear to auscultation
bilaterally.

Gastrointestinal

Abdomen
obese; BS active in all the four quadrants. Abdomen soft, nontender. No
hepatosplenomegaly.

Breast

Breast
is free from masses or tenderness, no discharge, no dimpling, wrinkling, or
discoloration of the skin.

Genitourinary

Bladder
is nondistended; no CVA tenderness. External genitalia reveals coarse pubic
hair in normal distribution; skin color is consistent with general
pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum
was inserted; vaginal walls are pink and well rugated; no lesions noted.
Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On
bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned
behind a slightly distended bladder; no fullness, masses, or
tenderness. No adnexal masses or tenderness. Ovaries are nonpalpable.

(Male:
Both testes are palpable, no masses or lesions, no hernia, and no uretheral
discharge.)

(Rectal
as appropriate: No evidence of hemorrhoids, fissures, bleeding, or
masses—Males: Prostrate is smooth, nontender, and free from nodules, is of
normal size, and sphincter tone is firm).

Musculoskeletal

Full
ROM seen in all four extremities as the patient moved about the exam room.

Neurological

Speech
clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert
and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye
contact. Speech is soft, though clear and of normal rate and cadence; answers
questions appropriately.

Lab
Tests

Urinalysis—pending

Urine
culture—pending

Wet
prep—pending

Special
Tests

Diagnosis

• Include
  at least three differential diagnosis
• Final
  diagnosis
• Evidence for final diagnosis should be documented in your Subjective
  and Objective exams.

PLAN
including education

• Plan:
• Further testing
• Medication
• Education
• Nonmedication treatments
• Follow-up