Concordia University Irvine
Division of Nursing
Geriatric Clinical Research Worksheet
Client initials: LC Allergies: No Known Allergies
Age: 72 Gender: Male Code Status: Full
Admission Date: 6/1/16 Unit & Room #: Not disclosed
Admitting Diagnosis: Near Syncope
Current Diagnoses/Problems: Dizziness, Confusion
Surgeries/Date (This admission): None
Past medical/surgical Hx: Patient Reports 2 stents 10 years previous at Saddleback Hospital. No record
in computer. Hypothyroidism, Smoking, ETOH, Hyperlipidemia, Diabetes Mellitus type 2, Coronary
Artery Disease, Hypertension.
Listed Medical Diagnosis (give Etiology/Pathophysiology Signs/Symptoms you expect to
medical dictionary definition) (what’s happening in the body) see (list general S&S for each
Start from the changes in patho and highlight ones pt
Dx tissue/cellular levels and end exhibited.)
Coronary Artery Disease- with some of the signs and
Narrowing of the symptoms. “Talk” to the
coronary arteries, usually pt/family. Coronary Artery Disease
as a result of Sx
atherosclerosis. (Taber’s Etiology Chest Pain
Medical Dictionary) Atherosclerosis refers to the Dizziness
thickening of the arterial wall Shortness of breath
Dx that is caused by an injury to Anxiety
Carotid Stenosis- a the endothelium. A buildup of Generalized Weakness
narrowing of the carotid macrophages, LDLs, and foam Irregular heart beats
arteries, the two major cells occurs that leads to the Tachycardia
arteries that carry formation of fibrotic plaque Activity intolerance
oxygen-rich blood from within the vessel wall that Diaphoresis
the heart to the brain. occludes the artery. Persons
(Mayfieldclinic) with diabetes mellitus type 2
are at an increased risk for
occlusion due to sugars. Carotid Stenosis
Increased glucose in the blood Sx
can cause damage to the Dizziness
endothelium and can cause Syncope during exertion
occlusion of the artery. In this Sudden Headache
case there is buildup in the Generalized Weakness
coronary arteries and a 70- Activity Intolerance
80% occlusion in the left and Inability to Speak
<50% in the right carotid Confusion
artery. This stenosis which is Nausea and Vomiting
caused by the buildup of
plaque is only made worse by
vasospasm cause by his
history of smoking,
Geriatric Assessment Worksheet 2016 Page 1 of 25
, hyperlipidemia, and
hypertension.
Geriatric Assessment Worksheet 2016 Page 2 of 25
, Lab Data (Reference ranges may vary.):
Date Date Date Date
H/L H/L H/L H/L Reference Range Notes
(time) (time) (time) (time)
6/1/16 6/2/16 N/A N/A
Hematology
WBC 9 8.7 3.6-11.0 K/UL
RBC 4.59 4.59 4.01-5.57 M/UL
Hgb 13.8 13.8 13.3-17.1 G/DL
Hct 42.6 42.3 37.7-49.9 %
MCV 93 92 80-100 FL
MCH 30.1 30.2 25.4-34.6 PG
MCHC 32.4 32.6 32-36 G/DL
RDW 14.4 14.3 11.5-14.5 %
Platelet 265 221 150-400 X 1000
MPV 10.1 10.4 7.4-10.4 FL
Neutrophils % 70.2 62.9 42-75 %
Lymphocyte % 22.1 22.4 21-51 %
Monocytes % 8.6 10.6 2.6-11.4 %
Eosinophil % 2.9 2.9 0-5 %
Basophil % 0.7 0.9 0-2 %
Bands % 0-5 %
PT 11.5-14.6 sec
INR 0.8-1.1
aPTT 22.2-34.8 sec
BNP <30 < 100 ng/L
Troponin I <0.015 < 0.04 ng/mL
Myoglobin 0-110 ng/mL
Male 3.0-7.4 mg/dL
Uric Acid Female 2.1-6.2 mg/dL
Cholesterol 124 < 200mg/dL
34 L > 40mg/dL A low value of HDL can
accelerate atherosclerosis
because there is a
HDL Cholester.
decrease in the reverse of
cholesterol transport.
More LDL is in the arteries.
CHOL/HDL 3.6 2.2-5.0
VLDL Calc 27 < 30mg/dL
Triglycerides 136 < 150mg/dL
LDL Chol Calc 63 0-129mg/dL
Geriatric Assessment Worksheet 2016 Page 3 of 25
Division of Nursing
Geriatric Clinical Research Worksheet
Client initials: LC Allergies: No Known Allergies
Age: 72 Gender: Male Code Status: Full
Admission Date: 6/1/16 Unit & Room #: Not disclosed
Admitting Diagnosis: Near Syncope
Current Diagnoses/Problems: Dizziness, Confusion
Surgeries/Date (This admission): None
Past medical/surgical Hx: Patient Reports 2 stents 10 years previous at Saddleback Hospital. No record
in computer. Hypothyroidism, Smoking, ETOH, Hyperlipidemia, Diabetes Mellitus type 2, Coronary
Artery Disease, Hypertension.
Listed Medical Diagnosis (give Etiology/Pathophysiology Signs/Symptoms you expect to
medical dictionary definition) (what’s happening in the body) see (list general S&S for each
Start from the changes in patho and highlight ones pt
Dx tissue/cellular levels and end exhibited.)
Coronary Artery Disease- with some of the signs and
Narrowing of the symptoms. “Talk” to the
coronary arteries, usually pt/family. Coronary Artery Disease
as a result of Sx
atherosclerosis. (Taber’s Etiology Chest Pain
Medical Dictionary) Atherosclerosis refers to the Dizziness
thickening of the arterial wall Shortness of breath
Dx that is caused by an injury to Anxiety
Carotid Stenosis- a the endothelium. A buildup of Generalized Weakness
narrowing of the carotid macrophages, LDLs, and foam Irregular heart beats
arteries, the two major cells occurs that leads to the Tachycardia
arteries that carry formation of fibrotic plaque Activity intolerance
oxygen-rich blood from within the vessel wall that Diaphoresis
the heart to the brain. occludes the artery. Persons
(Mayfieldclinic) with diabetes mellitus type 2
are at an increased risk for
occlusion due to sugars. Carotid Stenosis
Increased glucose in the blood Sx
can cause damage to the Dizziness
endothelium and can cause Syncope during exertion
occlusion of the artery. In this Sudden Headache
case there is buildup in the Generalized Weakness
coronary arteries and a 70- Activity Intolerance
80% occlusion in the left and Inability to Speak
<50% in the right carotid Confusion
artery. This stenosis which is Nausea and Vomiting
caused by the buildup of
plaque is only made worse by
vasospasm cause by his
history of smoking,
Geriatric Assessment Worksheet 2016 Page 1 of 25
, hyperlipidemia, and
hypertension.
Geriatric Assessment Worksheet 2016 Page 2 of 25
, Lab Data (Reference ranges may vary.):
Date Date Date Date
H/L H/L H/L H/L Reference Range Notes
(time) (time) (time) (time)
6/1/16 6/2/16 N/A N/A
Hematology
WBC 9 8.7 3.6-11.0 K/UL
RBC 4.59 4.59 4.01-5.57 M/UL
Hgb 13.8 13.8 13.3-17.1 G/DL
Hct 42.6 42.3 37.7-49.9 %
MCV 93 92 80-100 FL
MCH 30.1 30.2 25.4-34.6 PG
MCHC 32.4 32.6 32-36 G/DL
RDW 14.4 14.3 11.5-14.5 %
Platelet 265 221 150-400 X 1000
MPV 10.1 10.4 7.4-10.4 FL
Neutrophils % 70.2 62.9 42-75 %
Lymphocyte % 22.1 22.4 21-51 %
Monocytes % 8.6 10.6 2.6-11.4 %
Eosinophil % 2.9 2.9 0-5 %
Basophil % 0.7 0.9 0-2 %
Bands % 0-5 %
PT 11.5-14.6 sec
INR 0.8-1.1
aPTT 22.2-34.8 sec
BNP <30 < 100 ng/L
Troponin I <0.015 < 0.04 ng/mL
Myoglobin 0-110 ng/mL
Male 3.0-7.4 mg/dL
Uric Acid Female 2.1-6.2 mg/dL
Cholesterol 124 < 200mg/dL
34 L > 40mg/dL A low value of HDL can
accelerate atherosclerosis
because there is a
HDL Cholester.
decrease in the reverse of
cholesterol transport.
More LDL is in the arteries.
CHOL/HDL 3.6 2.2-5.0
VLDL Calc 27 < 30mg/dL
Triglycerides 136 < 150mg/dL
LDL Chol Calc 63 0-129mg/dL
Geriatric Assessment Worksheet 2016 Page 3 of 25
