satisfaction use of birth control methods HIV exposure Unknown Male GU

Satisfaction use of birth control methods hiv

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satisfaction; use of birth control methods; HIV exposure Unknown Male G/U Discharge from or sores on penis; testicular pain/masses Patient is female Female G/U Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP Vaginal discharge; itching; sores; lumps Menopause; hot flashes; post- menopausal bleeding; Unknown Peripheral Vascular Claudication; leg cramps; varicose veins; hx of blood clots Patient denies Musculo- skeletal Muscle or joint pain; joint stiffness Patient denies Neuro Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; involuntary movements Patient denies Heme Hx of anemia; easy bruising or bleeding; blood transfusions Patient denies Endo Heat or cold intolerance; excessive 4
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sweating; polydipsia; polyphagia; polyuria; glove or shoe size Patient denies Psych Nervousness/anxiety; depression; memory changes; suicide attempts Patient denies, also does not appear anxious or depressed General Findings and Physical Exam General Observations Does patient appear to be their stated age? Yes Level of consciousness Patient is alert and oriented x4 Skin color pink Nutritional status Patient appears healthy, denies any special diets or dietary changes Posture and position Patient is well balanced when standing and sits upright when sitting Obvious physical deformities No deformities noted Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement Patient has steady gait, walks without use of any device. Patient has strong, equal ROM in all joints with no involuntary movement noted. Facial expression No abnormal facial movements noted. Patient appears happy and calm Mood and affect Calm, follows commands, appears happy Speech: articulation, pattern, content and appropriate, native language Patient speaks fluently and coherently, content is appropriate. Hearing No hearing issue noted 5
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Personal hygiene Patient appears to be well kept with clean skin an hair Measurements and Vital Signs Weight 208 Height 5’5” BMI 34.6 Radial pulse: rate rhythm 68, rhythm is regular Respirations: rate depth 18, depth is regular with equal pause between each breath Blood pressure (indicate if sitting or lying) 122/82 (lying) Temperature (if indicated) 98.2 Pain assessment Denies pain Skin Hands and nails Hands and nails are appropriate for patient race and age, skin turgor snaps rapidly back to place, capillary refill less than 2 seconds Color and pigmentation Color is pink, appropriate for race and age Temperature Skin is warm to the touch Moisture No moisture noted Texture Skin is smooth with no lesions, scars or moles noted Turgor Skin turgor snaps rapidly back to place, Presence of lesions? No lesions noted to patient’s body Head and Face Scalp Hair Cranium Normocephalic, dry, even hair distribution, no evidence of trauma or lesions 6
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Face (cranial nerve VII) Symmetrical, cranial nerve VII intact Temporal artery and temporomandibular joint Temporal artery pulses symmetrical; temporomandibular joint without shifting, no
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  • Spring '16
  • Shelley Ashby

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