NSG 6020 Week 5 Exam Quiz Score A.

NSG 6020 Week 5 Exam Quiz Score A. UBJECTIVE: Chief Complaint: “I have had oily, runny stools for 3 months”. HPI: The patient is a 57 year old female who presents to the clinic today for oily stools for the last 3 months. The patient reports nothing makes it better or worse, and that somedays her stools are more solid, usually 2-3 days of the week, and other days they are quite liquid, and the toilet bowl is always full of a yellow oily substance, and when she wipes, there is bright yellow oil on the toilet paper. She also reports generalized abdominal pain that comes and goes at least once each day. It does not seem to get worse in any position, and seems to get worse a few hours after eating a meal. The patient is status post 6 months laparoscopic cholecystectomy, and reports she has lost 80 pounds since then by eating a more healthy diet, and by exercising every day for at least 30 minutes. Medications: None Allergies: Penicillin and sulfa. Patient reports she gets hives with both of these medications. Chronic Illnesses: none Hospitalizations: 6 months ago had cholecystectomy for several gallstones and acute cholecystitis. The patient denies any kidney, heart, lung, thyroid problems, stroke, diabetes, hypertension, and mental illnesses. The patient is a gravida 3 para 3, and denies any history of spontaneous abortions. Family History: The patient states her mother has hypertension but otherwise healthy and her Dad has low thyroid. She denies any family history for diabetes, heart disease, lung disease, kidney disease, mental illness, cancer, and mental illness. The patient also reports she is an only child. Social History: The patient lives in an apartment with her husband and teenage son. She reports she has been in a monogamous relationship for over 30 years. She reports she graduated high school and never went to college, and works as a receptionist at a local business. She denies any history of drug or alcohol use, and has never used tobacco. The patient reports she feels safe in her current home life, and denies questions about self-harm, or anyone doing harm to her. Review Of Systems: This study source was downloaded by from CourseH on :17:54 GMT -06:00 OBJECTIVE: Weight: 145 pounds BMI: 26 Temp: 98.2 F BP: 128/72 General: The pt reports a weight loss of 80 pounds over the last year from changing her diet to a more Mediterranean-type diet, and doing moderate exercise each day for lat least 30 minutes. The patient denies any fevers, chills, night sweats, or change in energy level. Cardiovascular: The patient denies any chest pain, palpitations, PND, orthopnea, or edema. Skin: The patient states she has a small itchy spot and rash under one of her abdominal folds of skin for the last year. She reports since she lost weight she has had trouble keeping the skin under her folds dry. She denies any bleeding, delayed healing, bruising, or changes is lesions or moles. Respiratory: The patient denies any cough, wheezing, hemoptysis, dyspnea, pneumonia history, or TB. Eyes: The patient denies the use of any corrective lenses, blurry or other vision changes. Gastrointestinal: The patient has had loose and oily stools for about 3 months. The patient denies any abdominal pain, nausea, vomiting, eating disorders, hemorrhoids, black tarry stools, and watery diarrhea. Ears: The patient denies any ear pain. Hearing loss, ear discharge, and ringing in the ears. Genitourinary/Gynecological: The patient denies any urinary burning, frequency, urgency, change in the color or odor of urine. She denies any history or exposure to STD’s. She reports her last pap smear was 1 year ago, last mammogram was 1 year ago, and denies any menstrual complaints. She states that her periods stopped about 1 year ago, and states she has not had any symptoms of hot flashes or vaginal bleeding since that time. She states she carried all 3 of her pregnancies to term and had all 3 of them vaginally with no complications. Nose/Mouth/Throat: The patient denies any sore throat, sinus discharge, dysphagia, dental disease, nose bleeds, or hoarseness. Musculoskeletal: The patient denies any back pain, joint pain or swelling, stiffness, fracture, or osteoporosis. Breast: The patient denies any changes in either breast, discharge, lumps, bumps. Neurological: The patient denies any seizures, dizziness, TIA’s, black out spells, transient paralysis, weakness, or parasthesias. Heme/Lymph/Endo: Patient denies history of HIV, unexplained bruising, pt has never had a blood transfusion; denies swollen glands, night sweats, increase hunger, thirst, or heat intolerance Psychiatric: pt denies any depression, anxiety, sleeping difficulties, suicidal ideation or attempts, and any previous psychiatric diagnoses.