History of Present Illness/Health
Review of Systems
General Overall Health: height: 6.1”, weight 346 pounds and BMI: 45.6
Skin: warm along with pink undertones found, no presence of bruising and was well perused, history of eczema or several other skin infections were not found
Hair: hair loss was absent and there was no change in texture of the hair as well
Nails: nails were strong and no change in shape was found
Head: mo presence or complain of headaches were found, no migraines, no prior injuries in the head were found.
Eyes: difficulty in vision was not found, it was clear
Ears: no earaches of infections were found
Nose and Sinuses: changes in the sense of smells were not found, no known allergies or discharge were found.
Mouth and Throat: inflammation of the gums, cavities and bad breath, chronic sore throat along with sudden excess of saliva, facing difficulty when swelling, feeling of lump throat and uncomfortable feeling
Neck: cervical lymph nodes were clear and proper in condition, no abnormal deviation of trachea was found, condition of the thyroid gland was also up to the mark
Breast/Axillae: palpation and percussion of the chest showed no negative condition, auscultation of the lungs also revealed no negative results; axillary lymph nodes were inspected and found in proper condition
Respiratory: chest x-ray showed the passage to be clear and there were currently no cough or sputum observed, symptoms of asthma, bronchitis, pneumonia or tuberculosis were not found. Mild ronchi that was present during emergency admission was also not found in the follow up and coughs were absent.
Cardiovascular: high blood pressure was found about 180/100 that was indeed a reason of concern, however complains of heart trouble was not reported, heart murmurs were not present, chest pain discomfort that was present during emergency admission was also not found, however some of the palpitations or skipped heartbeats were seen which might be due to cardiomegaly symptoms. Heart burns are also experienced by him sometimes probably due to his GERD conditions.
Peripheral Vascular: sweating was present and the palms were also found to be clammy, swelling in the legs mainly due to edema, no swelling or redness is found in the other parts of the body
Gastrointestinal: sometimes pain occurs in the abdomen, the pain might be due to the irritating effects of the stomach acids in the inner esophagus wall, this might be because the inner lining of the esophagus does not have the same natural protection from acid that exists in the stomach lining
Urinary: frequency or urination was found to be higher than that of the normal, nocturia is present with the needs of urinating 3 to 4 times per night, often suffers from incontinence or due to leakage of the urines, sudden urge to urinate, painful urination is also complained some of the times.
Genital: non-cancerous enlargement of the prostrate resulting in issues in urination, absence of scrotal pain and swelling, testicular pain and swelling are absence, no history of sexually transmitted disorders as well as the other sexual discomfort
Sexual Health: no sexual life as such, however complained if reduced sex drive and issue in keeping an erection along with less sexual satisfaction
Musculoskeletal: muscle of joint pain along with stiffness, arthritis and gout as well as backache and others are not present, swelling is however found in the legs that might be due to edema of cardiomegaly.
Neurological: fainting, blackouts and seizures are completely found to be absent along with no signs of dizziness, vertigo, numbness and tingling sensations. However, he suffers from low mood and sudden changes in mood, insight or judgment; however, he was polite and stable during the interview.
Hematologic: no complaints of anemia as well as easy bruising or bleeding and even past transfusion and transfusions reactions were present and found in the patients
Endocrine: excessive sweating was found that but did not show any signs of excessive thirst and hunger as well as polyuria and even change in glove or shoe size. No thyroid trouble and no heat or cold intolerance was also found.
Physical Assessment
Patient Name: _____Jack Green_________________________________________________
General Survey: ______________________________________________________
_________________________________________________________________
_________________________________________________________________
Ht.______6’1”____ Wt.__346________ Waist circumference__40 inches ________ BMI_____45.6_____
Snellen Vision Chart Right eye__no significant findings________ Left eye_____ no significant findings _____ Correction____ no significant findings _____
BP______180/100____ sitting/standing T__________ P__________ R__________
Pain Assessment: ___so pain was noted during the time of visit, chest pain and heart burn are found sometimes due to GERD._____________________________________________________
____________________________________________________________________
____________________________________________________________________
SKIN: sweating and clammy skin
HEAD AND FACE: no significant findings
EYES: (no significant findings)
EARS: no significant findings
NOSE: no significant findings
MOUTH: inflammation of the gums, cavities and bad breath, THROAT:
NECK: chronic sore throat along with sudden excess of saliva, facing difficulty when swelling, feeling of lump throat and uncomfortable feeling
CHEST AND LUNGS:
Anterior: clear (no significant findings)
Posterior: clear (no significant findings)
UPPER EXTREMITIES: (no significant findings)
BREASTS: (no significant findings)
NECK VESSELS: (no significant findings)
HEART: cardiomegaly (enlarged hart)
ABDOMEN: high abdominal circumference due to calorie deposition
INGUINAL AREA: no significant findings
LOWER EXTREMITIES: edema in both legs
NEUROLOGICAL: suffers from low mood (rest no significant findings)
MUSCULOSKELETAL: swelling is however found in the legs due to edema
GENITALIA: non-cancerous enlarged prostrate
HEALTH PROMOTION: State 3 areas where health promotion is needed for this patient.
a 1._the patient is not being able to understand the importance of healthy diet in his life and therefore, he is still having fast foods. The fast foods and the take-away foods are usually higher in calorie and hence results in calorie deposition in the body leading to increased weight content. Moreover, food low in salt content is also important for managing his blood pressure. Hence, healthy foods need to be consumed by him. _________________________________________________________________________
Patient Education: the patient should be included in a one-to-one education session where the nurse would use brochures, flyers and educational materials to help the patient understand the risks factors associated with taking fast foods. Developing his health literacy and making him understand his improper health habits would make him motivated to change his lifestyles. As he is keen on developing the condition of his health, these one to one discussion sessions with the patient may help in changing his dietary attributes.
2.__the patient has smoking habits and are seen not being able to reduce his smoking frequency. Smoking might also result in increased chances of high blood pressure. The chemicals in the tobacco smoke causes damage in the lining of the artery walls. This makes the walls of the artery to become narrow and these factors result in increasing the blood pressure because the blood has to flow through the narrow blood. This might result in life threatening situations and therefore it becomes very important for the nurse to educate the patient about it and change in outcomes________________________________________________________________________
Patient Education:
Motivational interviewing can be taken as the patient education strategy. The patient needs to be well aware about the harmful outcomes of smoking and needs to develop the motivation to withdraw smoking habits himself. Motivation interviewing technique would help in invoking the feeling and determination among the patient making him understand the outcomes of his sever smoking habits. When the nurse would be able to involve the patient successfully in the session, there would be high chance that the patient will develop motivation to overcome smoking habits and stick to his objectives. Smoking cessation planning should be developed for him and he should be also advised to participate in smoking cessation classes.
3._the patient seems to be withdrawn from his life as the loss of his wife had severe impact on the emotional stability of the patient. The patient feels low on mood that might be due to the grief of losing his wife who used to take good care of him and helped him to stay healthy. He seems to be depressed but he is unaware of this depression. With the passing of time, he might become more depressed and this might affect his quality of in life. Hence, the patient should be educated about the interventions and strategies that he can undertake to prevent him from being affected by the mental-disorder_________________________________________________________________________
Patient Education:
The patients should be first made to be aware of the symptoms of depression. This would help the patient to relate his own conditions with the symptoms of depression and accordingly be aware of his present mental health conditions. Accordingly, the patient would be allowed to understand and be educated about the treatment procedures of depression like the anti-depressant medications, therapy with the mental health specialists. The patient would be also educated about the strategy of the combination of mental health therapy and education and accordingly take part in the interventions to help him develop his mental state and live happy lives with family members. He can participate in cognitive behavioral therapy
| Rx Lisinopril | |
| Therapeutic Use | Administration Considerations |
| This medication is used for treatment of high blood pressure. Lowering of the blood pressure would help in prevention of many side effects that would include strokes, kidney problems and heart attacks. It is also used in the treatment for heart failures as well as improvement of a patient after heart attack | This medication should be taken by mouth with or without food as directed by the doctor and should be taken once daily by 20 mg |
| Side/Adverse Effects | Patient Instructions |
| Dizziness, lightheadedness, tiredness or headaches might take place on the administration of the medication | To reduce lightheadedness or dizziness, the patient should get up slowly from the sitting of the lying positions |
| Any other serious side effects are very rare but incidences of fainting symptoms of high potassium blood level resulting in muscle weakness, irregular heartbeats and many others are also noted in certain cases. | On seeing these symptoms, patients should immediately consult doctors |
| Rarely this medication causes liver problems | In cases, when people get symptoms like nausea, vomiting that does not stop, loss of appetite, abdominal pain, dark urine and yellowish skins, it might be due to liver damage and immediately patients should consult doctors. |
| This drug might also result in allergic reactions | This would include rash, itching and swelling like in face, throat and tongue along with several dizziness and troubled breathing. So then patients should immediately consult nurses. |
| Rx Simvastatin | |
| Therapeutic Use | Administration Considerations |
| This medication is used for the treatment of bad cholesterol level reduction in the individuals along with that of proper diet for maintenance of the levels of cholesterol levels. This should be taken in along with changes in habits like exercising, losing weight and other changes | This medication needs to be taken by mouth in the concentration of 20 mg daily with or without food if used in tablet form. If used in liquid for, it needs to be taken before food in empty stomach. |
| Side/Adverse Effects | Patient Instructions |
| Result in mild memory problems as well as confusion | These are rare effects and is they occur they need to be immediately disclosed to the nurses or other professionals |
| It might worsen diabetes | Patients should immediately make the professionals know if they have diabetes |
| Cause certain muscles problems sometimes leading to autoimmune myopathy and rhabdomylosis. | If symptoms like muscle pain as well as tenderness or that of weakness (especially with fever or unusual fatigue), signs of kidney problems (such as change in the amount of urine), the patient should immediately inform the doctors |
| Rx Esomeprazole | |
| Therapeutic Use | Administration Considerations |
| It is used for the treatment of certain types of stomach and esophagus problems like that of the acid reflux, ulcers and GERD. It helps in decreasing of the heartburn and even difficulty of swallowing and persistent cough. It helps in healing acid damage of the stomach and the esophagus. | About 40 mg of the medication should be taken in through mouth daily once about one hour before meal. |
| Side/Adverse Effects | Patient Instructions |
| Headache and pin in the abdomen might result | If any of the symptoms persist or worsen, the nurse should be told immediately |
| Low magnesium levels resulting in unusually fast, low or irregular heartbeat, muscle spasms and seizures might also result along with signs of lupus | The doctor should be immediately told and should be informed |
| It might result in vitamin b 12 deficiency. | Unusual weakness, sore tongue, or numbness/tingling of the hands/feet are some of the symptoms of vitamin b12 deficiency and hence this should be immediately identified by patient and told to doctors. |
