Matthew Meyer
Psychosocial Clinical Worksheet
Client initials: LW Allergies: No Known Allergies
Age: 92 Gender: Male Code Status: Full
Admission Date: 5/23/16 Unit & Room #: Omitted as required
Admitting Diagnosis: Acute MI
Current Diagnoses/Problems: Hopelessness, Risk for Suicide
Surgeries/Date (This admission): None
Past medical/surgical Hx: Benign prostatic hyperplasia, Chronic Kidney Disease, HTN, Hyperlipidemia, Pacemaker, Cardiac
Arrhythmia, DVT, Rhabdomyolysis
Listed Medical Diagnosis (give medical Etiology/Pathophysiology (what’s Signs/Symptoms you expect to see
dictionary definition) happening in the body) (list general S&S for each patho and
highlight ones pt exhibited.)
A myocardial infarction occurring when The ingestion of a bottle of sleeping
circulation to a region of the heart is pills into LW’s body was the - Chest Pain (dull or sharp),
obstructed and necrosis is occurring. precipitating factor that led to this Can be radiating into neck or
current medical emergency. The arms.
- Taber’s Medical Dictionary
sleeping pills that he took are
- Dyspnea
unknown,
- Profuse sweating
There is death of heart tissue resulting - Nausea
from coronary artery occlusion or other - Syncope
form of tissue necrosis. Most stem - Palpitations
from ischemia. Arteries can narrow to - Tachycardia
obstruct blood flow, or plaques can - Fatigue
break off from inside arteries and cause
an occlusion. Without oxygenated
blood flow tissue dies.
Lab Data (Reference ranges may vary.):
Date Date Date
H/L H/L H/L Reference Range Notes
(time) (time) (time)
5/25/1 5/26/1 N/A
6 6
Advanced Medical Surgical Clinical Summer 2016 Page 1 of 30
, Hematology
WBC 7.1 7.7 3.6-11.0 K/UL WBC are well within the
normal limits. These
values indicate that is no
immune response.
RBC 3.56 L 3.78 L 4.01-5.57 M/UL Levels are low here.
There are less RBC in
circulation. Circulating
red cells in the blood
toward diagnosing a
disease and monitoring
therapeutic treatment.
Hgb 10.4 L 11.3 L 13.3-17.1 G/DL Levels will vary
depending on the
peripheral circulation
and insufficient oxygen
levels. Evaluate anemia,
and perfusion.
Decreased Hgb from
changes of aging. Not
necessarily a
significantly low
number.
Hct 33.5 L 35.8 L 37.7-49.9 % Same as Hct. H/H can
run together. Decreased
Hct from changes of
aging. Not necessarily a
significantly low
number.
MCV 94 95 80-100 FL Used to diagnose and
monitor therapy for
diagnoses such as iron-
deficiency anemia. The
patient is receiving
Dextrose 5% NaCl 0.9%.
MCH 29.2 29.9 25.4-34.6 PG Provide screening as
part of a complete blood
count (CBC) in a general
physical examination,
Advanced Medical Surgical Clinical Summer 2016 Page 2 of 30
, especially upon
admission to a health-
care facility when there
is a history of HTN, or
poor blood flow.
Measuring of
hemoglobin
concentration.
MCHC 32.0 32.6 32-36 G/DL Provide screening as
part of a complete blood
count. To measure
health and apart of
MCH. Measuring of
hemoglobin
concentration.
RDW 13.2 13.2 11.5-14.5 % RDW It measures the
variability in red blood
cell size. It within the
normal limits.
Platelet 167 179 150-400 X 1000 Levels are normal here
but are low. There is no
immune response or
bleeding currently. The
patient will be able to
clot. Values are trending
upward.
MPV 9.9 10.1 7.4-10.4 FL Levels will vary
depending on the
peripheral circulation
and insufficient oxygen
levels. Used to evaluate
anemia, polycthemia
and hydration status.
Neutrophils % 72 78 H 42-75 % Monitor viral & bacterial
infection, he is within
the normal limits. It may
Advanced Medical Surgical Clinical Summer 2016 Page 3 of 30
Psychosocial Clinical Worksheet
Client initials: LW Allergies: No Known Allergies
Age: 92 Gender: Male Code Status: Full
Admission Date: 5/23/16 Unit & Room #: Omitted as required
Admitting Diagnosis: Acute MI
Current Diagnoses/Problems: Hopelessness, Risk for Suicide
Surgeries/Date (This admission): None
Past medical/surgical Hx: Benign prostatic hyperplasia, Chronic Kidney Disease, HTN, Hyperlipidemia, Pacemaker, Cardiac
Arrhythmia, DVT, Rhabdomyolysis
Listed Medical Diagnosis (give medical Etiology/Pathophysiology (what’s Signs/Symptoms you expect to see
dictionary definition) happening in the body) (list general S&S for each patho and
highlight ones pt exhibited.)
A myocardial infarction occurring when The ingestion of a bottle of sleeping
circulation to a region of the heart is pills into LW’s body was the - Chest Pain (dull or sharp),
obstructed and necrosis is occurring. precipitating factor that led to this Can be radiating into neck or
current medical emergency. The arms.
- Taber’s Medical Dictionary
sleeping pills that he took are
- Dyspnea
unknown,
- Profuse sweating
There is death of heart tissue resulting - Nausea
from coronary artery occlusion or other - Syncope
form of tissue necrosis. Most stem - Palpitations
from ischemia. Arteries can narrow to - Tachycardia
obstruct blood flow, or plaques can - Fatigue
break off from inside arteries and cause
an occlusion. Without oxygenated
blood flow tissue dies.
Lab Data (Reference ranges may vary.):
Date Date Date
H/L H/L H/L Reference Range Notes
(time) (time) (time)
5/25/1 5/26/1 N/A
6 6
Advanced Medical Surgical Clinical Summer 2016 Page 1 of 30
, Hematology
WBC 7.1 7.7 3.6-11.0 K/UL WBC are well within the
normal limits. These
values indicate that is no
immune response.
RBC 3.56 L 3.78 L 4.01-5.57 M/UL Levels are low here.
There are less RBC in
circulation. Circulating
red cells in the blood
toward diagnosing a
disease and monitoring
therapeutic treatment.
Hgb 10.4 L 11.3 L 13.3-17.1 G/DL Levels will vary
depending on the
peripheral circulation
and insufficient oxygen
levels. Evaluate anemia,
and perfusion.
Decreased Hgb from
changes of aging. Not
necessarily a
significantly low
number.
Hct 33.5 L 35.8 L 37.7-49.9 % Same as Hct. H/H can
run together. Decreased
Hct from changes of
aging. Not necessarily a
significantly low
number.
MCV 94 95 80-100 FL Used to diagnose and
monitor therapy for
diagnoses such as iron-
deficiency anemia. The
patient is receiving
Dextrose 5% NaCl 0.9%.
MCH 29.2 29.9 25.4-34.6 PG Provide screening as
part of a complete blood
count (CBC) in a general
physical examination,
Advanced Medical Surgical Clinical Summer 2016 Page 2 of 30
, especially upon
admission to a health-
care facility when there
is a history of HTN, or
poor blood flow.
Measuring of
hemoglobin
concentration.
MCHC 32.0 32.6 32-36 G/DL Provide screening as
part of a complete blood
count. To measure
health and apart of
MCH. Measuring of
hemoglobin
concentration.
RDW 13.2 13.2 11.5-14.5 % RDW It measures the
variability in red blood
cell size. It within the
normal limits.
Platelet 167 179 150-400 X 1000 Levels are normal here
but are low. There is no
immune response or
bleeding currently. The
patient will be able to
clot. Values are trending
upward.
MPV 9.9 10.1 7.4-10.4 FL Levels will vary
depending on the
peripheral circulation
and insufficient oxygen
levels. Used to evaluate
anemia, polycthemia
and hydration status.
Neutrophils % 72 78 H 42-75 % Monitor viral & bacterial
infection, he is within
the normal limits. It may
Advanced Medical Surgical Clinical Summer 2016 Page 3 of 30
