EliteDocs

What brings you in today? Reports difficulty sleeping and "feeling nervous" Why did you decide to seek treatment?? Reports seeking treatment because she has an upcoming exam and feels "too foggy to study" How do you feel just before bed? Reports excessive worry and racing thoughts before bed "I'm sorry to hear about your trouble sleeping and stress. I'm glad you came in. Let me learn more about what you're experiencing, and i will try to help."? Tina describes problems sleeping...

What brings you in today? Reports needing an annual physical What medical conditions do you have? Denies medical conditions What meds do you take? Reports taking occasional ibuprofen Do you take any prescription meds? Denies taking prescription medication Do you take any otc meds? Only otc medication is ibuprofen Why do you take advil? Takes ibuprofen to relieve menstrual cramps How often do you take advil? Takes ibuprofen monthly How many advil do you take at a time? Takes ...

Nursing Diagnosis Patient exhibits constipation related to deficient fiber and fluid intake, as evidenced by abdominal discomfort and tenderness, defecation fewer than two times per week, a distended abdomen, generalized fatigue, and a palpable abdominal mass Short term goal To induce a bowel movement that relieves the patient's constipation, resulting in patient reporting relief and diminished pain, within an emergency department visit. Interventions 1) Administer a mineral oil based ene...

Asked about numbness denies history of numbness denies current numbness Asked about tingling Denies tingling Asked about vision Reports vision problem Followed up on vision problems Reports vision problems for past few months Reports periods of blurry vision Reports vision problems occur only when reading Denies double vision Asked about headaches Reports occasional headaches Reports last headache was a few days ago Denies current headache Asked about headache patterns Reports hea...

Asked about foot wound reports swelling has improved reports wound warmth has improved reports wound discharge has improved reports wound is still a little red Asked about history of slow healing wounds denies history of slow healing wound Asked current wound healing time reports wound had been getting worse over the past week reports wound has improved with hospital treatment Asked about history of skin conditions reports acne reports dry skin denies skin cancer denies skin rashes...

Asked about asthma Reports having asthma Reports asthma exacerbations Asked about severity of asthma Reports asthma exacerbations occur up to 2 times a week Reports asthma exacerbations last around five minutes Asked most recent asthma exacerbation Reports last exacerbation was three days ago Reports last exacerbation around cats at cousin's house Asked about asthma triggers Reports cat allergy as asthma trigger Reports dust as asthma trigger Denies asthma problems at work Denies ...

Asked about heart problems -Denies heart problems Asked about heartbeat -- reports normal heartbeat - reports normal heart rate - denies palpitations - denies arrhythmia Asked about high blood pressure -- denies high blood pressure - reports last blood pressure check Finding: - reports last blood pressure check 140 over 80 or 90 - reports belief that current blood pressure is on the high side of normal range Asked about heart murmur -Denies heart murmur Asked about swelling ...

Normal lung sounds Bronchial, bronchovesicular, vesicular You can hear _______ sounds above the manubrium, over the trachea. These sounds are: -Harsh -High-pitched -Loud Bronchial ________ sounds are heard over the main bronchi. These sounds are: -Medium in loudness -Medium in pitch Bronchovesicular _______sounds are heard over the lower bronchi, the bronchioles, and the lobes. The left lung has two lobes. The right lung has three lobes. -Softest -Lowest in pith Vesicular Abnormal lu...

A patient has been given a new prescription for warfarin. Which statement indicates the need for additional teaching? - I will use a soft toothbrush while taking this medication - I can eat moderate amounts of foods with vitamin K on a regular basis - I should report unusual bleeding to my doctor - I can keep taking a daily aspirin to protect against heart disease (Correct Response) - I can keep taking a daily aspirin to protect against heart disease Aspirin increases the effect of warfar...

Patient Data Chief Complaint: Established chief complaint • Reports pain • Reports blood in urine • Reports increased frequency of urination Orientation: Asked about orientation • Oriented to own person • Oriented to place • Oriented to situation • Oriented to time History of Present Illness: Asked about onset and duration of symptoms • Reports pain began 3 days ago • Reports pain has gradually increased since onset • Reports increased urinary frequency bega...