Review the subjective and objective data sets provided in the 3 cases. You are to construct a subjective and objective data set for each case that demonstrates your knowledge of how to construct problem focused subjective and objective data sets.
Case 1 – S.H
CHIEF COMPLAINT:
“I HAVE NO CURRENT CONCERNS; ROUTINE CHECK IN FOR BLOOD PRESSURE AND MEDICATION”
HISTORY OF PRESENT ILLNESS:
(O)nset HYPERTENSION STARTED AT AGE 52 (L)ocation N/A (D)uration N/A (C)haracter N/A (A)lleviating/Aggravating factors N/A (R)aditation N/A (T)ime N/A
Patient is a 61 year old female that presents today with no complaints. She is routinely seen to monitor her blood pressure and check blood pressure medications. She was diagnosed with hypertension at age 52, 9 years ago.
PAST MEDICAL HISTORY:
Hypertension Mild heart attack Mild arthritis in bilateral hand History of anxiety and depression Bronchitis Kidney stones
ALLERGIES:
Seasonal allergies
CURRENT MEDICATIONS:
Metoprolol Ibuprofen
FAMILY HISTORY:
Mother: hypertension, stroke at age 65, skin cancer removed from shoulder
UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS
Father: pasted away of Lou Gehrig’s disease at age 62 Maternal Grandmother: Unknown to patient Maternal Grandfather: Unknown to patient Paternal Grandmother: Died of old age Paternal Grandfather: Heart disease, died of complications from heart disease
SOCIAL HISTORY:
mother of 2 full-time job as accountant Does not smoke cigarettes Does not use illicit drugs Drinks socially with friends once or twice a month
HEALTH PROMOTION:
Patient due for Cholesterol, Hepatitis C, HIV/AIDS screening Due for colonoscopy to screen for Colon Cancer Immunizations are up to date Patient had Pap and mammogram done last year
ROS:
General- Denies any weight changes recently. Appears well groomed. No reports of weakness, fatigue, or fever.
Skin- Denies rashes, lumps, sores, itching, dryness, or changes to color of skin. No changes to moles or nails. Hair is starting to turn gray.
HEENT- No report of headaches, dizziness, or light headedness. Patient wears glasses. Denies, pain redness, spots, flashing lights, tearing, glaucoma or cataracts. Denies issues with hearing, tinnitus, earaches, vertigo, or infection. Does not suffer from frequent colds, nasal stuffiness, itching, nosebleeds, or sinus trouble. Reports no problems with teeth or gums, dentures, or dry mouth. Denies frequent sore throats or hoarseness.
Neck- Denies any swollen glands, lumps, pain or stiffness in neck.
Breasts- Denies, lumps, pain, or discharge from breasts. Performs self-exam once a month.
Respiratory- Denies shortness of breath, cough, wheezing or pain. Patient states that she tends to get bronchitis easily in the winter is she develops a cold.
UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS
Cardiovascular- Patient reports high blood pressure. States that a couple years ago she was under a lot of stress and reported having mild heart attack and has not had symptoms since. Denies chest pain or discomfort, murmurs, palpitations, shortness of breath, and swelling of extremities.
Gastrointestinal- Denies trouble swallowing, heartburn, nausea, or vomiting. No changes in appetite or bowel habits.
Peripheral vascular- Denies leg pain, cramps, clots, swelling or changes to color in extremities.
Urinary- Denies changes to urgency or frequency of urination. No recent blood or infection present. Patient has been treated for kidney stones in the past. Reports no incontinence.
Genital- Patient has completed two pregnancy and is menopausal
Musculoskeletal- Patient reports mild arthritis in hands. Denies all other joint pain, stiffness, gout, or backaches. Denies swelling, redness, pain, weakness, tenderness, or limitation to range of motion.
Psychiatric- Denies nervousness, mood, memory changes, suicidal ideations. Patient suffered depression when her father died and spoke with counselor at the time. Currently does not feel depressed.
Neurologic- Denies changes to mood, attention span, orientation, or speech. Reports no changes to memory or judgement. No headaches, dizziness, vertigo, or fainting.
Hematologic- Denies easily bruising or bleeding.
Endocrine- Denies excessive sweating, thirst or hunger. Reports no history of thyroid problems.
PHYSICAL EXAM:
General- Patient appears well groomed and dressed appropriately. Walks with normal gait and motor function. Patient is alert and orientated. Normal mood and affect.
Vital Signs- Blood pressure: 124/88, HR: 87, Resp: 16.
Skin- Appropriate moisture and temperature. Multiple freckles on face, arms. and legs. No apparent lesions. Inspection of hair is of normal texture and distribution. Nails are of normal color with no deformities. Patient is starting to grow grey hair. Nothing to note from palpation of scalp. Good turgor. No rashes or bruising.
UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS
HEENT-
Head – Normocephalic, no visual or palpable masses. Face and skull symmetrical. Eyes – Eyes are in alignment. Conjunctiva clear. Sclera appears white. Pupils are
equal, round, and reactive bilaterally. Extraocular movements intact bilaterally. Patient wears glasses.
Ears – Inspection of ear within normal limits. No problems with hearing bilaterally. (Do not have proper equipment to complete exam)
Nose – Inspection of nasal mucosa, septum and turbinate within normal limits, no lesions or inflammation. No tenderness with palpation of maxillary and frontal sinuses.
Throat – Inspection of oral mucosa, gums, teeth, tongue, palate, tonsils, lips, and pharynx within normal limits (pink, equal, aligned)
Neck- Inspection and palpation of cervical lymph nodes note no masses. No deviation in the trachea. No enlargement of thyroid noted.
Respiratory- Inspection and palpation symmetrical with no masses or abnormalities noted. Clear to auscultation and percussion.
Cardiovascular- Regular rate and rhythm, no murmurs, or gallops.