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Chart Project

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by

Ashley VanLiere

on 15 January 2013

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Transcript of Chart Project

The Life Of... F.Q. Medical Diagnosis Physiological Psych Response Room B10
Sex: Female
Admitted on 8/26/2010
Marital Status: Widowed, 1 year Background General:
Lupus

Circulatory:
Anemia
Angina
Hypertension (HTN)

Respiratory:
Asthma
Pneumonia Norvasc for hypertension
Lopressor for hypertension She has anxiety and insomnia
She goes for walks with a lady down the hall.
Sits with a group of ladies during meals.
Other than that she isn't social.
She had great memory, She could tell me stories from her childhood. Her husband is pasted away a year ago
She has 2 son.
Her religious views are Baptist.
She was born in Grand Rapids
She was married for 61 years
She was born on 1/24/1929 Musculoskeletal:
Osteoporosis
Osteoarthrosis

Neurological:
Anxiety
Insomnia Lupus Chronic inflammatory disease that occurs when the body's immune system attacks its own tissues and organs. Anemia Deficiency of red blood cells or hemoglobin Angina Discomfort of the heart muscle when it doesn't get enough oxygen enriched blood Hypertension High blood pressure Asthma Spasms in the bronchi Signs and Symptoms:
fatigued
headaches
joint pain
fever
anemia
swelling of limps
chest pain
hair loss
blood clotting
ulcers Can effect:
joints
skin
kidneys
blood cells
brain
heart
lungs Signs and Symptoms:
appear pale
shortness of breath
fatigue easily
tired Signs and Symptoms:
pressure in the chest, shoulders, arms, neck, jaw or back
may feel indigestion
underlying heart problems Signs and symptoms:
headaches
fatigue
confusion
vision problems
difficulty breathing
irregular heartbeat
blood in urine
pounding in neck, chest, or ears Signs and symptoms:
coughing
wheezing
shortness of breath
chest pain, pressure or tightening Circulatory Respiratory Pneumonia inflammation one or both lungs caused by bacterial viral infection Signs and Symptoms:
chills
fevers
chest pain
cough
nausea
vomitting
muscle ache
rapid breathing
rapid heartbeat
shortness of breath Osteoporosis Bones become brittle and fragile from the loss of tissue Signs and Symptoms:
back pain
loss of height
stooped position
bone fractures Osteoarthrosis Degenertaion of joint cartilage and the underlying bone Signs and Symptoms:
pain in joints
stiffness
muscle weakness
swelling of joints
deformed joints
reduced range of motion Anxiety Being anxious Signs and Symptoms:

Feeling apprehensive
Feeling powerless
Having a sense of impending danger, panic or doom
Having an increased heart rate
Breathing rapidly
Sweating
Trembling
Feeling weak or tired Insomnia Difficulty falling and/or staying asleep Signs and Symptoms:
Waking up tired
waking up during the night
difficulty falling asleep Prednisone to decrease inflammation Digestion Lactobacillus to build bacteria in the vowel
Miconazole topical ointment for yeast infections
Pepcid for GERD to decrease gastric acid Metabolic Panel:

protein 5.9L
albumin 3.2L
11/27/2012 Complete blood count: White blood cell count: 10.9 (high)
Red blood cell count: 3.66(low)
11/27/2012 Muscleskeletal Tylenol for pain
Vicodin for pain
Fentanyl transdermal for pain Recommendations Look into seeing if all medications are needed End Thoughts She is put together well.
Living at the assisted living center is right for her because they can watch all her diagnosis and she doesn't have worry about it.
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