Tuesday, December 24, 2019

Subjective Data. Chief Complaint Headaches On And Off

Subjective Data: Chief Complaint: Headaches on and off for three days, routine monthly visits for hypertension, diabetes, and, glaucoma evaluations. History of Present Illness: Mr. A. O. a 66 year-old-African American male came in the clinic for a monthly routine follow up visit complaining of severe cluster frontal headaches that radiates to his left eye, pain level eight out of ten, on and off for three days lasting for 30 to 45 minutes. He stated that he takes Tylenol 1000mg orally every eight hours with mild relieve, and will like his blood pressure medications increased. Also, he complained of edema to the upper and lower extremities, and right hand pain when he tries to make a fist. However, he denied shortness of breath,†¦show more content†¦Ears: Denies ringing in the ear or hearing impairment. Nose: Denies nasal discharge, congestion, or problems with his sense of smell. Throat: Denies problems with his gums and mouth. Swallows without any difficulty. Neck: Denies any edema or bruises around the neck. Respiration: Denies labored breathing. Cardiovascular: Denies chest pain, but complained of edema to the upper and lower extremities. Gastrointestinal: Denies anorexia, nausea and vomiting, heartburn, abdominal pain, or constipation. Endocrine: History of Type two diabetes, he stated that his blood before breakfast was 95. Objective Data: Vital signs: Temperature 98.7 Fahrenheit, BP 200/140 Pulse 80, Respiration 18, weight 345 IBS, BMI of 35. Generalized appearance unkempt and obese Skin: Warm to touch, dry and intact. Head: Normocephalic, Atraumatic. Ears: No discharge or cerumen noted bilaterally, tympanic membrane normal without redness or edema Nose: Nares patent without any obstruction. No frontal or maxillary tenderness during palpation of the sinus cavities. Pharynx: Oral mucus membrane moist, dental cavities and plague. No edema noted Neck: No palpable lump, carotids without bruit Cardiac: Regular rhythm without murmur, normal S1and S2. One plus edema to bilateral lower extremities. Capillary refills are presents and carotid bruits are absent. Respiratory: Lung sounds are clear on auscultation without rales, rhonchi, or wheezes. Respiration unlabored withShow MoreRelatedEssay The Cycle of Nursing Theory2708 Words   |  11 Pagesnurse organizes is based off of theory, and revolves directly around the patient. The current practice used as a Registered Nurse in the emergency room setting is similar, but less complicated than that of an Advanced Practice Nurse Practitioner. Emergency room nurses firstly ask the patient what their chief complaint is upon arrival. The chief complaint labels the patient, and gives them a triage level based on the amount of resources needed to intervene. The chief complaint (or illness) is theRead MorePneumonia Case Study1647 Words   |  7 Pagesoccurs only in the lobar form. An increasing number of viruses are being identified as the cause of respiratory infection. Half of all pneumonias are believed to be of viral origin. Most viral pneumonias are patchy and the body usually fights them off without help from medications or other treatments. Pneumococcus can affect more than the lungs. The bacteria can also cause serious infections of the covering of the brain (meningitis), the bloodstream, and other parts of the body. Community-acquiredRead MoreCare Plan for Hypertension3392 Words   |  14 Pagestook her back to the hospital with complaints of chest pain and palpitations. Pt was more confused than usual and was having increased difficulty in gait. Physician suspected pt to have some left-sided weakness greater than left-sided weakness and chest pain. A second CT of the brain turned up normal. VS stable, but pt remains confused, weak, complains of some dizziness and palpitations. Physician referred pt for admission to nursing home with admitting chief complains: chest pain, palpitationsRead MoreMental Health Case Study7435 Words   |  30 Pages Mental Health Case Study LS Nicole Castro College of Southern Nevada Division of Nursing Mental Health Nursing Clinical NURS 243C-S10 Micki Lin Mongogna-Alarcon, MA, BSN, RN October 18, 2010 Mental Health Case Study DM Demographic Data: LS is a 44 year-old female of African and Hispanic decent. She was born in California but moved to Las Vegas as a teenager. She stated that she attended Clark High School and went to a â€Å"stewardess college† in California. She worked as a stewardessRead MoreOccupational Stress: Causes and Management11211 Words   |  45 Pagesrepetitive habits. In other extreme situations, the person may develop diseases or conditions such as migraines, asthma, stomach and skin problems, aches and pains, flu, etc. These signs come about as a result of the physical well-being of the person being off balance (Crouter and Manke, 1994). Mental stress is often seen when the person has sleeping disorders that make them either sleep less or more than usual, constant feeling of worry, anxiety or confusion, frequent mood changes such as frustration,Read MoreAdvanced Professional Development21653 Words   |  87 Pagespotential and help make selections for promotion. Although they take place off the job, they include work-related activities and group work, as well as counselling and psychometric assessments, so they can be included under the heading of work-based methods. They are expensive to run, so are mainly for large organisations. 360-degree feedback Appraisals and even performance and development reviews can be perceived as subjective and over-dependent on the views of the person doing the reviewing. TheRead MoreMGT1FOM Key Management Theorists26579 Words   |  107 Pagesdeveloped punched cards strung together to make a chain and to fall at the appropriate time with a hole signaling the loom to lift a thread and become part of the design, or a blank that stopped a thread. The Jacquard loom anticipated the binary zero/one, off/on system of George Boole’s algebra that formed the principle for modern computer operations. Babbage borrowed Jacquard’s concept, but demonstrated foresight in his use of punch cards for the storage of information as well as the guidance of machineRead MoreAccounting Information System Chapter 1137115 Words   |  549 Pagesobjective may require sacrificing another. For example, ensuring that information is more complete may reduce its timeliness. Similarly, increased verifiability and reliability may reduce its timeliness. The decision maker must decide which trade-offs are warranted in a given situation. 1-1 Ch. 1: Accounting Information Systems: An Overview 1.3 You and a few of your classmates decided to become entrepreneurs. You came up with a great idea for a new mobile phone application that youRead MoreAnnotated Bibliography: Plagiarism39529 Words   |  158 Pagessubstantial passages are taken from previous published work and slightly edited to change words or phrases so that they are superficially different. The first of these is clearly dishonest. You are, in effect, stealing other peoples work and passing it off as your own. In doing so you are claiming credit for something that it not your own. It may be that the agency that is funding the work is being defrauded by paying for something that is not original: it may be that the publisher is unknowingly putRead MoreHuman Resources Management150900 Words   |  604 Pages18%. Over 40 work teams meet regularly to discuss work goals, track their performance against established measures, and discuss problems and issues. Employee turnover is also extremely low in most areas. Transitions in HR management are also paying off in the Bank of Montreal, based in Montreal, Quebec. Emphasizing human resources has involved 35,000 employees in organizational success. This recognition meant focusing greater attention on the talents of diverse employees working at the bank. Specific

No comments:

Post a Comment

Note: Only a member of this blog may post a comment.