Week 6 ihuman

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School

Chamberlain University College of Nursing *

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Course

602

Subject

Medicine

Date

Apr 3, 2024

Type

docx

Pages

3

Uploaded by GrandIronOkapi39

Report
Past medical history Croup at age two. Right wrist fracture from rollerblading at age 11. Hospitalizations None Medications Ibuprofen as needed for croup Allergies None Family History Father: HTN, Obesity Mother: Obesity Maternal Grandmother: Type 2 diabetes Maternal Aunt: Type 2 diabetes Social history She reports social alcohol use, denies recreational drug use. Physical exam Patient appears alert and oriented x 4. Appropriate attire and hygiene, poor eye contact. No abnormalities noted. Sclera is clear, pupils are equal and reactive to light. Conjunctiva is healthy pink normal for ethnicity. Ear are visualized to be clear, tympanic membrane is flat and pearly gray. Nares are non-swollen or discolored. No Pharyngeal erythema or exudate. Neck is non-tender with trachea midline. Heart sounds are clear, no murmurs, arrythmias, or other abnormal sounds heard. Chest is symmetrical, respirations are even and unlabored. Lung sounds are clear in all lobes. Abdomen is obese with striae. Soft and non-tender to palpation. No hepatomegaly. All extremities are visualized to be without swelling or deformity. Non-tender to palpation. Cranial nerves II-XII are intact, DTR are normal, no involuntary movements, physical sensation intact. Mild facial acne, stretch marks noted on the abdomen, Acanthosis nigricans on neck. Skin otherwise normal for age and ethnicity. No enlarged lymphnodes
She presents with a teary affect and poor eye contact for the situation. Problem statement Treatment plan A.C. is a 17 y.o female who presents for fatigue for the past 2 months. Subjective evaluation is significant for reports of unintentional weight gain, lack of interest in previously pleasurable activities, social isolation from family and friends, low self- esteem, and daily crying spells. Objective findings are significant for weight gain of 26 pounds since last visit, abdominal striae, and acanthosis nigricans. Patient denies active suicidal ideation, endorses passive death wish. No significant past medical history or family history. Medications: Fluoxetine 10 mg PO once daily in the morning. Referral: Provider will refer the patient to an in-network psychologist for talk therapy. Patient will also be referred to a nutritionist for counseling on a healthy diet. Client education: Anti-depressants can take 6-8 weeks to fully take effect. Thoughts of suicide can increase within the first few weeks - should this occur contact your local 24/7 crisis line (888-796-8226 Resolve Crisis Network), Dial 911 or go immediately to the nearest emergency room. If you start to feel better after a few weeks remember it is vital to continue to take your medications as prescribed. Common side-effects can include nausea, diarrhea, insomnia, fatigue, dizziness, headache and other symptoms.
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