Orthopnea polyuria female reprod hematologic chng

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Orthopnea Polyuria Female Reprod. Hematologic Chng Voice x Palpitations Scrotal Masses/Pain Abnormal Menses Anemia Dentures PND STD’s Dryness Easy Bruisability Epistaxis Gastrointestinal Urgency Dyspareunia Enlarged LN’s Hoarseness BRBPR Sexual Abuse HxTransfusions Sinusitis Chng Bowel Habits Vaginal Discharge Comments: CC: ____Chest pain ___Persistent and unremitting substernal chest pain__________________________________________________________________________________________________ ____________________________________________________________________________ Initial: __6 hours ago _________________________ HPI: (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Assoc. Signs/Symptoms) ____Chest pain of central location with radiation to the left arm and jaw. Quality of a severe chest pain Severe enough to prevent patient mobilization and requiring analgesics and morphine. The timing refers to the last 6 hours of continuous chest pain. Context. It happened at the dinner table at lunch time. Modifying factors. None. Only lying down provides some relief to the patient. Associated signs and symptoms. Signs Persistent pain with sharp or knife pain characteristics with radiation to left arm down to the index finger and the jaw and throat. Patient is sweeting and abdominal pain in the epigastrium area. He is not able to talk or complain for the last couple of hours. Symptoms. Mild fever, lightheadedness, mild confusion, shortness of breath, hypotensive and showing signs of starting to loose consciousness _______________________________________________________________________________________________________________ ____Medical assessment from the Professional Nursing care documentation Department in Acute Care _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
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___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ PMH Reviewed – No Changes; See Adult Summary Form PMH Reviewed & Updated; See Adult Summary Form SHx Reviewed – No Changes; See Extended Hx Form SHx Reviewed & Updated; See Extended Hx Form FHx Reviewed – No Changes; See Extended Hx Form FHx Reviewed & Updated; See Extended Hx Form Vital Signs: Age: ____________ Weight: _310___________BMI: __39.8___________Temperature: ___100.7__________Blood Pressure: _100/45________not discernible_____Pulse: _______________ Respirations: _28_______ Fingerstick: _____________ LMP: _____________ Oxygen Saturation: __87_____________ Initials: _________ Physical Exam: Nl Ab General Nl Ab Nl Ab Nl Ab Nl Ab MSK x Appearance x Auscultation xx Bowel Sounds Axillary Inspection VS x Percussion Palpation Inguinal Exam of Joint
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  • Fall '19
  • Physical examination, Available ,   PND

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