NU 627 Week 6 Case Study A score guaranteed

Subjective data:  “I feel dizzy.”  Increased thirst and urination starting this morning.  reporting dizziness started about 10 hours ago.  First noticed the dizziness when he got up to use the bathroom early this morning.  Finds it to be constant and has mild headache.  He does not associate the situation with any aggravating factor  His glucose was 128 this afternoon, he does not check his glucose in the morning. Objective data:  Vital signs:T- 98.6 F, HR- 89 RR- 16, BP - 160/97 mmHg, pain 2/10  Pulse ox - 95%, Wt.: 187 lbs. Ht 68 in, BMI 28.43  General appearance: No acute distress, well-nourished and cleanly kept.  HEENT: Normocephalic, face symmetrical. PERRLA, Conjunctiva pink, sclera white. Cornea and lens are clear. Normal fundus exam. Auditory canal intact and clear, TM appears grey and intact, no effusion, bulging or erythema noted. Bony landmarks and light reflex visualized bilaterally. Hearing intact. Oral mucosa moist