*NURSING > CASE STUDY > Western Michigan University__ Week 5 Option 1__Already Graded A (All)

Western Michigan University Week 5 Option 1Already Graded A

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S: losing 12 lbs. over the last month HPI Onset: last month Location: generalized Duration: 12 Lbs. over the last month Characteristic: purposely losing weight? Changed diet? presenting any loss ... of appetite? Nausea? Vomiting? Aggravating factors: any stressors? Does the smell of food causes nausea? Any problems with swallowing or with dentures? Any medications causing bad taste? Relieving factors: trying small meals? Soft food? Trying bland diet? Treatment: taking any meal supplements? Any vitamins? Any medications to increase appetite? Severity: loss 12 lbs. over the last month PH: DM, ask if patient has psychiatry history, ask patient for any surgical history, past medical history, genetic predisposition, family past medical history, reason of death. Social History: ask regarding tobacco, alcohol, drug use Allergies: ask about medication, environmental and food allergies. Add reaction Medications: ask about routine and OTC medications, dosage, frequency and reason for medication treatment. Some medications may cause decrease of appetite. Immunizations: ask about immunization status (last TD, pneumococcal, flu and zoster vaccine) ROS: General: change of diet, fever, chills, weakness, night sweats, fatigue, feeling forgetful? HEENT: presenting any URI symptoms, travel out of country, any sick contact? coughing after eating or drinking? Difficulty to swallow or shocking feeling? Losing taste? Any gum pains? Difficulty to chew? Presence of dentures? Need of dentures or replacement? Cardiac: any chest pain, discomfort or palpitations? Respiratory: any cough, chest congestion, shortness of breath or difficulty? GI: any abdominal pain or discomfort, LBM, constipation, diarrhea, n/v? color and consistency, frequency? GU: any burning or discomfort to urinate? unable to completely void, or feeling that is taking too long, incontinence? Odor, color? Musculoskeletal: experiencing any weakness on either side of the extremities? Loss of coordination or balance? O: [Show More]

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