Heart And Blood Vessel Assessment

644 WordsNov 24, 20143 Pages
Jacob Powell Write-up for Heart and Blood Vessels Date: 10/18/2013 Time: 1330 Biographical: G.B., 20, Male, Caucasian, DOB: 01/23/1993, Student, Dr. Wang, Orientated to person, time and place, reliable source of information. No deficits in mental ability. Write-up for Heart: History of Present Illness- Chief Complaint- Fatigue Denies chest pain Fatigue is persistent, but not strong enough to interfere with capabilities Denies associated symptoms Denies medication Denies cough Denies difficulty breathing Denies loss of consciousness Symptom Analysis- Where- Symptoms systematic States “I always seem to be tired.” When- Symptoms began three months ago Symptoms onset was gradual Last entire duration of the day What- Rated pain 0 out of 10…show more content…
High intensity Denies sexual activity Denies use of illegal drugs Risk Factors Male, more at risk Denies hyperlipidemia Denies elevated homocysteine level Denies smoking Denies family history of cardiac disease Denies diabetes mellitus Denies obesity Denies sedentary lifestyle Positive personality, somewhat intense Write-up for Blood Vessels: History of Present Illness- No CC Denies leg pain or cramps Denies swollen ankles Past Medical History- Denies cardiac surgery or hospitalization for cardiac evaluation or disorder, congenital heart defect, or vascular procedures Denies acute rheumatic fever, unexplained fever, swollen joints, or vasculitis Hypertension noted, denies bleeding disorder, hyperlipidemia, diabetes, thyroid dysfunction, stroke, transient ischemic attacks, coronary artery disease, atrial fibrillation, or thrombophlebitis Family History- Denies family member with risk factors, morbidity, mortality related to cardiovascular system, hypertension, dyslipidemia, diabetes, heart disease, thrombosis, peripheral vascular disease, or abdominal aortic aneurysms Personal and Social History- Denies employment Denies tobacco use Healthy nutritional status Usual diet consist of a large amount of carbs and sugars, low amounts of protein and fat Denies weight gain or loss Denies alcohol use Exercises with weights twice a week for one
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