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*NURSING > iHuman Case Studies > I HUMAN WEEK 4 EXAM (All)

I HUMAN WEEK 4 EXAM

Document Content and Description Below

I HUMAN WEEK 4 EXAM Amber Waddell Subjective Jennifer Alberson Chief complaint: trouble sleeping History of present Illness: Patient is a 65 year old female. Patient presents with complai ... nts of trouble sleeping. Stared a couple months ago and was intermittent. Now it is multiple times a week. Patient has problems both falling asleep and staying asleep. Patient tosses and turns for 1-2 hours trying to go to sleep then wakes up at 2- 3AM and has trouble going back to sleep. Patient is a light sleeper and awakes with noise. Review of system: Constitutional: Patient reports feelings of nerviousness. Denies depression, anxiety. Increase in weight loss. Denies fevers Head/ neck: she has occasional headaches. Denies a decrease in ROM in the neck. Denies vertigo or dizziness. Denies any pain in the neck. EENT: denies sinus pain or pressure. Positive for nasal congestion and runny nose. Denies ear pain or pressure. Negative for tongue or lip swelling. Able to handle oral secretions. Denies changes in vision. Denies double vision or blurriness. Cardiac: palpitations, Respiratory: denies chest pain or pressure. Denies chest tightness GI: Has feelings of heart burn. Has frequient bowel movements. Denies abdominal pain, nausea or vomiting. Heme/ Lymph: Denies swollen lymph nodes or bruising. Skin: denies skin color changes, rashes, or open wounds. Patient states hair is thinning Muscular: denies change in gait. Denies pain in arms and forearms. denies muscle weakness of the legs or feet. Denies pain of the legs or feet, denies stiffness. Medical history: none [Show More]

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