Heart And Blood Vessel Assessment

Decent Essays
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-
Symptoms systematic
States “I always seem to be tired.”
Symptoms began three months ago
Symptoms onset was gradual
Last entire duration of the day
Rated pain 0 out of 10
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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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