NR 601 Week 6 iHUMAN ASSIGNMENT- JANET RILEY
-
$20.00
| Institution | Chamberlain |
| Contributor | Isabelle |
Last Visit 1 year and 1 month ago:
- ROS
- No complaints, “a little forgetful from time to time, but I think that’s normal at my age.”
- PMI
- HTN, CAD dx at age 55; post stent placement in left main coronary artery: dx at age 65. Hypercholesterolemia: dx at age 55 occasional insomnia; bilateral sensorineural hearing loss (with hearing aids)
- Medications
- No medication change- Atorvastatin 40mg, Lisinopril 20mg, Atenolol 50mg, HCTZ 12.5mg, aspirin 81mg, zolpidem 5mg prn for insomnia
- Family History
- Mother- deceased at age 83- suspected CHF; father-deceased at age 72- prostate cancer; brother-deceased at age 59-bladder cancer- 2-adult children-healthy and grandchildren
- Social History
- Elementary school teacher for 35 yrs, retired 9 yrs ago. Husband passed away 2 yrs ago. Alcohol and drugs: occasionally at family gatherings- Diet: dairy intolerance
Physical Exam
- Temp- 98.6
- Pulse-62 bpm, rhythm regular
- Bp- 136/84
- Rr- 14
- Weight- 120 lbs
Deferred on systems not checked
Assessment/Plan
The patient has been transferred due to PCP retired. Only received partial medical records
Asked patient to schedule a full check-up within the next month with a physician or NP
Current Visit
Observations:
- Skin- warm and dry
- Odor- excessive body odor
Physical Exam (Intake)
- Weight- 110 lb (loss 10lbs since last visit)
- A and O x 2 (not very alert and oriented)
- Temperature- 98.9
- Pulse- 68bpm rr: strength normal
- Bp- left- 142/86, right 142/86: elevated. Pulse pressure: normal
- RR- 14 rr unlabored……….. Continue
| Instituition / Term | |
| Term | Uploaded 2023 |
| Institution | Chamberlain |
| Contributor | Isabelle |
