NU 627-unit 10 discussion Anemia, Infectious Disease
NU 627 Geriatric Healthcare
Unit 10 Discussion
Anemia, Infectious Disease
Natasha Schlumbrecht
Pertinenet Positives
CC: “ I am always tired.”
HPI: JL 71 y.o . F reports feeling tired for the last three months but recently has noticed shortness
of breath when walking up the steps and sleeping more. She has noticed some issues with her
memory as well.
PMH: depression taking Sertraline 50 mg PO daily
ROS:
General: Has been sleeping more and fatigue.
Respiratory: Has noticed shortness of breath with going up her steps at home or physical activity.
NS: Does notice some numbness and tingling at times. Has noticed more forgetfulness at times.
Skin: Wife reports pale appearance.
Objective:
Constitutional: pale appearance.
HEENT: Conjunctiva pale, . Angular cheilitis . Tongue smooth and beefy appearance
Respiratory: Has noticed shortness of breath with going up her steps at home or physical activity.
CV: slight murmur is noted.
Skin: pale and dry.
Pertinenet Negatives
HPI: She denies CP, weight gain/loss, poor appetite or swelling. She denies abdominal pain,
N/V/D. She denies vaginal bleeding, bloody or dark tarry stools. She denies taking NSAIDs, or
ETOH use. She had a normal colonoscopy 5 years ago.
PMH: GERD 2016, taking Omeprazole 20mg PO daily
Allergies: No known drug allergy.
Social History
NU 627-unit 10 discussion Anemia, Infectious Disease
, She is retired and lives with her wife and they live off their pensions and SSI. The couple lives
alone and follow a vegetarian diet. Denies alcohol, illicit drug use, tobacco use.
Family History- Her brother, and 2 sisters are alive and well; not diagnosed with any chronic
condition. Her parents are deceased, and not diagnosed with any chronic condition. Paternal
grandmother was diagnosed with hypertension, while paternal grandfather suffered from heart
disease.
Health Maintenance- UTD on all immunizations and cancer screenings for age. Has had
diabetes, HTN and cholesterol screenings which were all within no rmal limits.
Review of Systems
General: Denies fever, chills, sleeping difficulties, and weight loss/gain. Denies poor appetite
lightheadedness or dizziness. Reports eating a healthy vegetarian diet.
HEENT: Denies ear ache, nasal discharge, headache, or sore throat. Denies visual abnormalities.
Respiratory: Denies cough, trouble breathing nor wheezing.
CV: Denies chest pain, palpitations and leg edema.
GI: Denies Abd pain, N/V/D. No bloody or dark tarry stool GYN: Denies vaginal bleeding
GU: Denies dysuria, hesitancy and hematuria.
MSS: No joint pain nor swelling.
NS: Patient denies weakness in strength, headache.
Psychiatric: She feels like her depression is currently well managed. Denies anxiety.
Objective Data
125/ 95mmHg. 88 bpm. 17RR. 98.5 degrees Fahrenheit , Oxygen saturation 100%.
Height 5 feet 4 in. Weight 130 pounds.
Constitutional: Alert, oriented, dressed appropriate, pale appearance.
HEENT: Normocephalic. Lids/lashes/orbit unremarkable. No discharge. PERRL, EOMI.
External ear canals no abnormalities observed.
Neck: Supple with no lymphadenopathy nor masses. No thyromegaly noted. No tracheal
deviation.
Normal range of motion. No distended jugular veins.
Respiratory system: No deformities noted, no respiratory distress. Chest region is clear to
auscultation.
NU 627-unit 10 discussion Anemia, Infectious Disease
NU 627 Geriatric Healthcare
Unit 10 Discussion
Anemia, Infectious Disease
Natasha Schlumbrecht
Pertinenet Positives
CC: “ I am always tired.”
HPI: JL 71 y.o . F reports feeling tired for the last three months but recently has noticed shortness
of breath when walking up the steps and sleeping more. She has noticed some issues with her
memory as well.
PMH: depression taking Sertraline 50 mg PO daily
ROS:
General: Has been sleeping more and fatigue.
Respiratory: Has noticed shortness of breath with going up her steps at home or physical activity.
NS: Does notice some numbness and tingling at times. Has noticed more forgetfulness at times.
Skin: Wife reports pale appearance.
Objective:
Constitutional: pale appearance.
HEENT: Conjunctiva pale, . Angular cheilitis . Tongue smooth and beefy appearance
Respiratory: Has noticed shortness of breath with going up her steps at home or physical activity.
CV: slight murmur is noted.
Skin: pale and dry.
Pertinenet Negatives
HPI: She denies CP, weight gain/loss, poor appetite or swelling. She denies abdominal pain,
N/V/D. She denies vaginal bleeding, bloody or dark tarry stools. She denies taking NSAIDs, or
ETOH use. She had a normal colonoscopy 5 years ago.
PMH: GERD 2016, taking Omeprazole 20mg PO daily
Allergies: No known drug allergy.
Social History
NU 627-unit 10 discussion Anemia, Infectious Disease
, She is retired and lives with her wife and they live off their pensions and SSI. The couple lives
alone and follow a vegetarian diet. Denies alcohol, illicit drug use, tobacco use.
Family History- Her brother, and 2 sisters are alive and well; not diagnosed with any chronic
condition. Her parents are deceased, and not diagnosed with any chronic condition. Paternal
grandmother was diagnosed with hypertension, while paternal grandfather suffered from heart
disease.
Health Maintenance- UTD on all immunizations and cancer screenings for age. Has had
diabetes, HTN and cholesterol screenings which were all within no rmal limits.
Review of Systems
General: Denies fever, chills, sleeping difficulties, and weight loss/gain. Denies poor appetite
lightheadedness or dizziness. Reports eating a healthy vegetarian diet.
HEENT: Denies ear ache, nasal discharge, headache, or sore throat. Denies visual abnormalities.
Respiratory: Denies cough, trouble breathing nor wheezing.
CV: Denies chest pain, palpitations and leg edema.
GI: Denies Abd pain, N/V/D. No bloody or dark tarry stool GYN: Denies vaginal bleeding
GU: Denies dysuria, hesitancy and hematuria.
MSS: No joint pain nor swelling.
NS: Patient denies weakness in strength, headache.
Psychiatric: She feels like her depression is currently well managed. Denies anxiety.
Objective Data
125/ 95mmHg. 88 bpm. 17RR. 98.5 degrees Fahrenheit , Oxygen saturation 100%.
Height 5 feet 4 in. Weight 130 pounds.
Constitutional: Alert, oriented, dressed appropriate, pale appearance.
HEENT: Normocephalic. Lids/lashes/orbit unremarkable. No discharge. PERRL, EOMI.
External ear canals no abnormalities observed.
Neck: Supple with no lymphadenopathy nor masses. No thyromegaly noted. No tracheal
deviation.
Normal range of motion. No distended jugular veins.
Respiratory system: No deformities noted, no respiratory distress. Chest region is clear to
auscultation.
NU 627-unit 10 discussion Anemia, Infectious Disease
