Subjective Data
Chief Complaint (CC):
The patient is a 35-year-old woman with a complaint of frequent headaches occurring over the past two weeks.
History of Present Illness (HPI):
The patient reports that she has never had issues with headaches prior to two weeks ago. She states she may have a headache after a stressful day; however, denies premenstrual headaches or frequent headaches. The patient reports the headaches started two weeks ago, occurring 3-5 times per week. The headaches are on the left side in the temporal area, throbbing, and severe, a 7 on a scale on 1-10, with no radiation reported. The patient reports some nausea with the headache and at times seeing “spots in front of her eyes” right before the onset of the headache. The headaches last for several hours and are relieved if she is able to get some sleep. She has tried Ibuprofen with no relief. She reports she retreats to a dark and quiet corner when the headaches start. The patient reports no trouble with her vision, no epistaxis, no upper respiratory symptoms, or sinus issues. She
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While this individual is in the clinic, it is imperative to review her spiritual, social, psychological, and cultural well-being. This allows the provider to take a holistic approach in treating this individual by reviewing immunizations, activity levels, dietary intake, and stress factors. This allows the practitioner to identify areas for improvement and potential needs for follow up for this individual. It would also be prudent to review risk factors, screening needs, and modifiable factors including weight, social habits, diet, and lifestyle choices. From this information, a plan for health and illness prevention can be determined. By taking, an active approach in the development and identification of patient healthcare needs can drastically decrease mortality and morbidity leading to a long, healthy life (Dunphy et al.,
On 03/28/2016 I, Deputy Daniel Pruitt was dispatched to 5150 Stonewall Terrace for a complaint.
This patient is a 35 y/o young women with a new diagnosis of breast cancer. Problems are the diagnosis of breast cancer, dehydration, and depression. Her depression is affecting her nutritional intake which is causing her malnutrition and poor intake. As an RN, I would encourage her to increase her daily intake and encourage
Pt c/o 7/10 tension headache with light sensitivity x 1 week and half. He states that his headaches originates in the back of his head and neck. He denies SOB, n/v, facial dropping, numbness or tingling, or sensitivity to nose. Tried to offer pt the next available and home care advice. Pt refused to listen. Pt states that he is going to the ER. Informed Cpt Lam the pt
1.) Describe the method or methods you would use to determine priorities for both existing and potential services that the Lakeview Medical Center might offer.
After implementing these strategies, the patient’s weight will be measured and recorded weekly to track the progress (Ramont, Niedringhaus, & Towle, 2012). The level of food intake will also be measured considered plus random questions to determine the memory of the patient. However food intake will be at top of the list, this is because most of the issues surrounding the patient usually have a direct effect on the food intake of the patient. The other technique will be through observation where I will observe whether her joints are healing and whether the inflammation is reducing. Moreover, lack of depression will be determined by how happy she is which is also noticeable through observation (Daly, 2012).
Gadsden is located in the northeastern corner of Alabama and is the county seat of Etowah County. It is 60 miles
She continued to have forgetful episodes and migraines. She rated pain as 7-10 in severity. A total of 12 therapy visits was recommended.
in England a serious case review is an examination of all the evidence presented if a child dies as a result of suspected or actual abuse or neglect. Other parts of the uk have their own
She reports a history of back pain, ovarian cysts excision, and breast tumor. She denies chest pain, shortness of breath, or palpitations. Patient reports that her immunizations and preventive care are up to
Patient states that she has had no head injuries, past or present. Patient states she has never suffered from vertigo or dizziness. BB states that she rarely suffers from generalized headaches. Patient avoids taking pain relievers of any kind when she does present with head pain.
All cranial nerves tested within normal limits. Pt passed visual fields exam and no problems with gag reflex. Pt moved muscles evenly and bilaterally and was able to shrug shoulders and move head from side to side.
Sally’s headaches normally start at work were she is an administrative assistant at a local hospital. Sally describes the headache as a “tight band around her head” and the headaches have increased in frequency over the last thirty days. She also states they pain starts in the back of her neck and back of her head. Questions to ask are? Do you use a computer a lot? Do you feel stressed at work? Have you started any new medications? Have you had any dental work in the last 30 days? Do you find your work stressful?
Results of a fact-finding mission about the state of the war concerning the British Empire, the German Empire, the Soviet Socialist Republics, the Kingdom of Italy, and the Empire of Japan. The fact-finding mission was conducted at the request of President Franklin Delano Roosevelt for the planning of future American diplomatic and military policies. The objective of the mission was to evaluate each of the major parties currently engaged in armed conflict and create an action plan based of the combined results of the evaluation. Each evaluation examines the diplomatic, military, economic, and territorial state of each Country as well as any potential dangers that may be presented to the security and interests of the United
Work Specialization refers to the degree of organization of work is divided into a number of steps to complete the task and different person completes each step. Based on the case, Buckman Lab is divided the tasks to different skilled people to finish in the past. Now, Buckman Lab is less work specialization in the K,Neti-knowledge network. Hence, Employees are involved in variety roles such as providing information, answering question and so on.
Patient also, has history of hypertension, GERD, morbid obesity, anemia, and depression. She reported that the past few months, she has been feeling very weak and overall generalized deconditioning. Her ability to care for herself including her activities of daily living (ADLs), and her basic physical needs (like bathing, grooming, ambulation, meal preparation, transportation, errands, and housekeeping), had decreased, and cannot consistently carry them out.