Student Documentation Model Documentation died of stroke 78 Paternal

Student documentation model documentation died of

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Student DocumentationModel Documentationdied of stroke-78 -Paternal grandmother-still living-82 years old- hypertension Paternal gransdfather-died of colon cancer at age of 62-type 2 diabetes -Patient denies any family history of kidney disease, sickle cell anemia and mental illnesses. Review of Systems: Subjective: -General- denies any chills, no weakness, no fever, no dizziness -Head: denies any headaches, head trauma, no migraines. -Eyes-no current eyes problems-history of blurry vision,denies wearing glasses, vison gets blurry after reading for long periods of time. -Ears-denies hearing loss, no tinnitus Nose/Sinuses- denies current sinus problems, denies nosebleed. -Throat-denies hoarsness, no mouth wounds, no cuts, no throat pain, no swallowing problems. -Cardiovascular- denies chest pain, denies palpitations -Respiratory-denies shortness of breath, no sputum, no wheezing -Gastrointestinal- complains of abdominal pain, no nausea- no vomiting -Genitourinary-denies any problem voiding, no urinary tract infection history -Neurology- denies dizziness, syncope, paralysis, no numbness, no problem with balance. -Muskuloskeletal- denies current back pain no muscle pain, no joint pain -Hematology- denies bleeding -Lymphatics- denies nodules enlargements, no lymphedema -Psychiatric- denies anxiety and no depression -Endocrinology- denies cold or heat intolerance, denies polyuria, no polydispsiaObjectiveTemp- 99.6 BP- 138/80 HR- 80 RR- 15 Pulse Ox- 98% Weight- 85 kg BMI- 29.4 Blood Glucose- 131 -Head-skull-symmetrical, no balding, no thinnng of hair, no masses, no tenderness noted, 28 years old patient appears clean, well dressed, primary historian, no distress noted, posture maintained. HEENT: symmetrical bilaterally, no lesions, no discoloration, mucus membrane moist and pink- normal skin turgor, no tenting. -Abdomen- symmetrical, rounded, no visible abnormalities, no masses, no distention, no laceration, no bruising noted. -Bowel sounds normoactive on all quadrants -All areas generally tympanic - Light palpation-No tenderness reported, no guarding, no mass. -Deep palpation- no palpable mass reported -Abdominal Aorta- auscultated- no bruit -Renal arteries- no bruit -Iliac arteries- no bruit -Femoral arteries- no bruit -Liver- not palpable- Liver span percussion 7 cm in the mid-clavicular line -Spleen- tymapny, no dullness, not palpable General: Ms. Jones is a pleasant, obAmerican woman in no acute distreShe maintains eye contact throughoAbdominal: Abdomen is soft and prlesions; skin is warm and dry, withopresent and normoactive in all quaddeep palpation. Tympanic througho
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  • Fall '15
  • Irritable bowel syndrome, Gastroesophageal reflux disease

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