Health Assessment for RNs: Case study

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Sangita Maharjan

Gesundheit & Medizin

 Name: Chavarria, Tomasa
 Age: 71 years
 Gender: Female
 Marital Status: Widow
 Occupation: Retired.
 Race: Hispanic
 Education: Second Grade
 Language spoken: Bilingual; Spanish and
English

 Source of history: patient and her records.
 Present illness: Numbness and tingling
sensation in the left side of body and unable
to coordinate walk well for three days.
 Admitted to inpatient Rehabilitation center.
 Past health: Non smoker or non alcoholic
 Type 2 diabetes Mellitus
 Hypertension,
 CVA 6 years ago.
 Family History: Unknown, client unable to
remember.
note: the client's name has been
changed for privacy and
confidentiality purpose.

 Birth Place: Reynosa, Mexico.
 Immigrant since 1980.
 Religion: Jehovah’s Witness( does not accept
blood products)
 She has two sons and lives with one of her
sons in one story house in Mission, Texas.
 Her son works extensive hours, she spends
many hours at home by herself.
 She was independent ambulatory without
assistive device before current admission.

 No known Allergies
 Neurological: Alert oriented; time, person,
date, place, situation. Pleasant and
cooperative
 Vitals signs: WNL
 Skin: Status post fall at home; skin
discoloration dry Scabs to bilateral knees and
left foot. and small painless nodule over the
bridge of the nose. No fever or chills or Rash.

 Mouth and throat: Difficult to swallow,
Dysarthria, Dystmetria
 Continence bowel and bladder.
 Difficulty opening right eye, gaze preference
to right eye, Hemianopia.
 Other remaining systems: Within Normal
Range. No significant abnormality was found
on assessment.
 Laboratory Finding: WNL

 Decreased endurance, Left sided weakness,
impaired dynamic balance.
 Left side Neglect, she tends not to see left
field, difficult to recognize movement and
difficulty in following commands given from
left side field.
 Dysmetria and Dysarthria but able to speak
and comprehend.

 Aspirin 81 mg PO daily
 Lipitor 40 mg PO at bed time
 Plavix 75 mg PO daily
 Amaryl 4 mg PO twice a day
 Glucophage 100 mg PO twice daily
 Hemocyte plus 1 tab PO daily
 Lovenox 40 mg subcutaneous daily
 Diet: 1800 ADA Mechanical ground, thin
liquid.

 During taking health history and physical
examination, some issues regarding her
condition and disease were discussed:
 The importance of participating in her daily
exercise and her ADLS such as daily shower,
PT/OT activities to promote her
 independency during stay in rehabilitation
center and at home.

 Bladder and bowel Training: the importance
of regular toileting to prevent incontinence,
retention and bowel bladder accidents.
 Aspiration Precaution: Sitting position and
Modified texture of diet.
 Have assistance at all the time to prevent
fall/injuries.
 Prevention of decubitus ulcers : Frequent
repositioning and avoid long time sitting in
wheel chair.

 Her past history of Diabetes, stroke
hypertension might have contributed in
occurrence of her current stroke.
 Discussed the importance of keeping her
blood pressure and blood sugar controlled.
 The importance of following diet
modification, low salt, low fat, low cholesterol
diet, diabetic diet. Consultation with
physician, nurses and dietary specialist.

 The importance of continuation of medication
prescribed by physician. In order to prevent
anemia( Jehovah's Witness) by diet and
vitamins supplements as prescribed.
 Psychological support: discussed the benefits
of adopting a day by day approach and avoid
as much as possible engaging into the types
of thinking that can exacerbate her anxiety,
also discussed her successful therapy results
and the reasons to be optimistic in regard to
her progress.

 Jarvis (2012).Physical examination & health
assessment (6th ed). St. Louis, Mo:
Elsevier/Saunders.


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Henry is a 70-year-old African American male with end-stage renal disease (ESRD) started recently on hemodialysis 3 times per week and is having trouble with the diet changes. He dislikes the taste of his binders (Tums 8/ /calcium carbonate) and reports often forgetting to take them with meals. His nephrologist referred him for help implementing a renal diet. He went through a class but is having trouble remembering what he leamed. He is present at the appointment with his adult daughter. Henry was diagnosed with type 2 diabetes 10 years ago. The doctor said it was likely that he had DM for several years prior to diagnosis. Henry lives alone but his daughter lives a few miles away and takes him to his dialysis appointments or else he takes medical transportation. Henry is mostly homebound, and his daughter brings groceries. She describes him as "set in his ways." He often eats canned and frozen meals because they are easy to prepare, and he likes them. He feels fatigued and doesn't have energy to cook but will heat things up and his daughter will sometimes make food for him and bring it over. His ankles appear swollen. "I sleep a lot at dialysis so I can't sleep at night very well - plus I get a lot of muscle cramps which keeps me awake." His urine output is 240mL/ day and he has chronic constipation with a BM every 2 to 3 days. Anthropometrics: Height: 70 inches /178cm Weight: 153lbs/69.5kg BMI: Weight 1 year ago: 170lbs, Weight 3 months ago: 159lbs, Weight before last dialysis session: 165 lbs, Weight after last dialysis session: 160 tbs Here Is Henry's 24 Hour Recall: B: Often skips as he sleeps late and doesn't have much of an appetite lately. Drinks 1 cup coffee with 2 tbs half and half when he wakes up. 5: (11 am) 12 oz orange juice and 1 slice white toast with butter, small handful of M&M's L (1:00 pm): 2 cups canned tomato soup (tomato is his favorite) 12 saltine crackers and 8 oz 2% milk. 5: 1 large banana D (8 pm): Salisbury steak with mashed potatoes frozen dinner and 12 oz sweetened iced tea. S: (10 pm) 1 cup chocolate ice cream Medications and Supplements: atenolol, erythropoietin (EPO), ferrlecit, insulin (lantus basil insulin), zemplar, sertraline, miralax, calcium carbonate tablets Nutrition Physical Exam: Evidence of moderate wasting in the orbital, buccal, temporal and clavicular regions. Patient moves slowly and dentures appear to fit loosely. He falls asleep briefly during the nutrition intake. Ankles have evidence of edema.Nutrition Physical Exam: Evidence of moderate wasting in the orbital, buccal, temporal and clavicular regions. Patient moves slowly and dentures appear to fit loosely. He falls asleep briefly during the nutrition intake. Ankles have evidence of edema. Recent Labs and Blood Pressure: Blood Pressure (BP): 143/92 Question 1 Assess Henry's anthropometrics. Has he lost weight? Gained weight? Has he gained more than the recommended amount between dialysis sessions? Calculate his calorie, protein, and fluid ne.

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Assignment Details Diabetes Case Study Chief Complaint “My left foot feels weak and numb. I have a hard time pointing my toes up.” History of Present Illness D.T. is 42-year-old Caucasian woman who has had an elevated blood sugar and cholesterol 2 years ago but did not follow up with a clinical diagnostic work-up. She had participated in the state’s annual health screening program and noticed her fasting blood sugar was 160 and her cholesterol was 250. However, she felt “perfectly fine at the time” and did not want to take any more medications. Except for a number of “female infections,” she has felt fine recently. Today, she presents to the clinic complaining that her left foot has been weak and numb for nearly 3 weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. She does report that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 50 pounds since her last pregnancy 10 years ago, 20 pounds in the last 6 months alone. Past Medical History Seasonal allergic rhinitis (since her early 20s) Breast biopsy positive for fibroadenoma at age 30 Gestational diabetes with second child 10 years ago Multiple yeast infections during the past 3 years that she has self-treated with OTC antifungal creams and salt bath Hypertension for 10 years Past Surgical History C-section 14 years ago OB-GYN History Menarche at age 11 Last pap smear 3 years ago Family History Type 2 DM present in older brother and maternal grandfather. Both were diagnosed in their late 40s. Brother takes both pills and shots. Mother alive and well Father has COPD Two other siblings alive and well All three children are alive and well Social History Married 29 years with 3 children; husband is a school teacher Family lives in a four bedroom single family home Patient works as a seamstress Smokes 1 pack per day (since age 16) and drinks two alcoholic drinks 4 days per week Denies illegal drug uses Never exercises and has tried multiple fad diets for weight loss with little success. She now eats a diet rich in fats and refined sugars. Allergies NKDA Medications Lisinopril 10 mg daily Loratadine 10 mg daily Review of Systems General Admits to recent onset of fatigue HEENT Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing: Denies vertigo, head trauma, ear pain, difficulty swallowing or speaking Cardiac Denies chest pain, palpitations, and difficulty breathing while lying down Lungs Denies cough, shortness of breath, and wheezing GI Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits occasional episodes of constipation GU Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or .

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Chief Complaint “My left foot feels weak and numb. I have a hard time pointing my toes up.” History of Present Illness D.T. is 42-year-old Caucasian woman who has had an elevated blood sugar and cholesterol 2 years ago but did not follow up with a clinical diagnostic work-up. She had participated in the state’s annual health screening program and noticed her fasting blood sugar was 160 and her cholesterol was 250. However, she felt “perfectly fine at the time” and did not want to take any more medications. Except for a number of “female infections,” she has felt fine recently.Today, she presents to the clinic complaining that her left foot has been weak and numb for nearly 3 weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. She does report that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 50 pounds since her last pregnancy 10 years ago, 20 pounds in the last 6 months alone. Past Medical History Seasonal allergic rhinitis (since her early 20s)Breast biopsy positive for fibroadenoma at age 30Gestational diabetes with second child 10 years agoMultiple yeast infections during the past 3 years that she has self-treated with OTC antifungal creams and salt bathHypertension for 10 years Past Surgical History C-section 14 years ago OB-GYN History Menarche at age 11Last pap smear 3 years ago Family History Type 2 DM present in older brother and maternal grandfather. Both were diagnosed in their late 40s. Brother takes both pills and shots.Mother alive and wellFather has COPDTwo other siblings alive and wellAll three children are alive and well Social History Married 29 years with 3 children; husband is a school teacherFamily lives in a four bedroom single family homePatient works as a seamstressSmokes 1 pack per day (since age 16) and drinks two alcoholic drinks 4 days per weekDenies illegal drug usesNever exercises and has tried multiple fad diets for weight loss with little success. She now eats a diet rich in fats and refined sugars. Allergies NKDA Medications Lisinopril 10 mg dailyLoratadine 10 mg daily Review of SystemsGeneral Admits to recent onset of fatigue HEENT Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing: Denies vertigo, head trauma, ear pain, difficulty swallowing or speaking Cardiac Denies chest pain, palpitations, and difficulty breathing while lying down Lungs Denies cough, shortness of breath, and wheezing GI Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits occasional episodes of constipation GU Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or urinary incontinence EXT Denies leg cramps or swelling in the ankles and feet; has never experienced weakness, tin ...

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Sample Soap Note: Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension) Student Name Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Rafael Camejo Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name : Mr. DT Age : 68-year-old Gender at Birth: Male Gender Identity : Male Source : Patient Allergies : PCN, Iodine Current Medications: · Atorvastatin tab 20 mg, 1-tab PO at bedtime · ASA 81mg po daily · Multi-Vitamin Centrum Silver PMH: Hypercholesterolemia Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago. Preventive Care : Coloscopy 5 years ago (Negative) Surgical History : Appendectomy 47 years ago. Family History : Father- died 81 does not report information Mother-alive, 88 years old, Diabetes Mellitus, HTN Daughter-alive, 34 years old, healthy Social History : No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone. Sexual Orientation : Straight Nutrition History : Diets off and on, Does not each seafood Subjective Data: Chief Complaint : “headaches” that started two weeks ago Symptom analysis/HPI: The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting. Review of Systems (ROS) CONSTITUTIONAL : Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC : Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures. HEENT : HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. RESPIRATORY : Patient denies shortness of breath, cough or hemoptysis. CARDIOVASCULAR : No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea. GASTROINTESTINAL : Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. GENITOURINARY : Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. MUSCULOSKELETAL : Denies falls or pain. Denies hearing a clicking or snapping sound. SKIN : No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data: VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10. GENERAL APPREARANCE .

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Soap Note 2 Chronic Conditions Soap Note Chronic Conditions (15 Points) Pick any Chronic Disease from Weeks 6-10 Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Follow the MRU Soap Note Rubric as a guide Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement SOAP NOTE SAMPLE FORMAT FOR MRC Name: LP Date: Time: 1315 Age: 30 Sex: F SUBJECTIVE CC: “I am having vaginal itching and pain in my lower abdomen.” HPI: Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN. Current Medications: Protonix 40mg PO Daily for GERD MTV OTC PO Daily Advil 200mg OTC PO PRN for pain PMHx: Allergies: NKA & NKDA Medication Intolerances: Denies Chronic Illnesses/Major traumas GERD Hospitalizations/Surgeries Denies Family History Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known med ...

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Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension) Student Name Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Rafael Camejo Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name : Mr. DT Age : 68-year-old Gender at Birth: Male Gender Identity : Male Source : Patient Allergies : PCN, Iodine Current Medications: · Atorvastatin tab 20 mg, 1-tab PO at bedtime · ASA 81mg po daily · Multi-Vitamin Centrum Silver PMH: Hypercholesterolemia Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago. Preventive Care : Coloscopy 5 years ago (Negative) Surgical History : Appendectomy 47 years ago. Family History : Father- died 81 does not report information Mother-alive, 88 years old, Diabetes Mellitus, HTN Daughter-alive, 34 years old, healthy Social History : No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone. Sexual Orientation : Straight Nutrition History : Diets off and on, Does not each seafood Subjective Data: Chief Complaint : “headaches” that started two weeks ago Symptom analysis/HPI: The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting. Review of Systems (ROS) CONSTITUTIONAL : Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC : Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures. HEENT : HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. RESPIRATORY : Patient denies shortness of breath, cough or hemoptysis. CARDIOVASCULAR : No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea. GASTROINTESTINAL : Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. GENITOURINARY : Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. MUSCULOSKELETAL : Denies falls or pain. Denies hearing a clicking or snapping sound. SKIN : No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data: VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10. GENERAL APPREARANCE : The patient is aler.

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1 2 SOAP Note Patient with UTI United State University FNP xxx: Common Illness Across the Lifespan -Clinical Practicum Dr. xxxx SOAP Note Patient with UTI ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian. Client’s Initials: L.U Age :65 years. Race: African American Gender: Female Date of Birth: 08 Insurance: BlueCross BlueShield . Marital Status: Married Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”. CC: Pain and burning during urination. HPI: Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment. ROS Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain. Eyes: Denies double vision, change in vision factors, or blurry vision. Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion. Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain. Pulmonary: Denies Gastrointestinal: c/o moderate to severe pain in the abdominal area. Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days. Musculoskeletal: Denies any kind of pain Integumentary & breast: Denies issues Neurological: Denies issues Psychiatric: Denies any kind of depression or mood swing Endocrine: Denies having any problem Hematologic/Lymphatic: Denies Allergic/Immunologic: No Known allergy Past Medical History: · Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold. · Denies history of chronic medical problems with father or mother. · Preventative care: None indicated · Surgeries: Denies · Hospitalizations: Denies · LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section. Allergies: No known food or drug allergy · Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...

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