Heart And Blood Vessel Assessment
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
Sleep more than usual
Symptoms do not fluctuate
This indicates that patient may have RBC problem
How-
Stated “I have no idea how I am still tired after the amount of sleep I get.”
Full-time student
Patient is in no pain, rather apathetic about symptoms
Social support from friends and family
Why-
Assumes it is a blood or hormone problem
No methods of treatment noted
Past Medical History-
Denies cardiac surgery or hospitalization for cardiac evaluation or disorder
Denies rhythm disorder
Denies acute rheumatic fever, unexplained fever, swollen joints, inflammatory rheumatism, Sydenham chorea (St. Vitus dance), abdominal pain, skin rash, or nodules
Hypertension noted, denies bleeding disorder, hyperlipidemia, diabetes, thyroid dysfunction, coronary artery disease, obesity, and congenital heart defect
Family History-
Denies long QT syndrome
Denies diabetes
Denies heart disease
Denies dyslipidemia
Hypertension noted
Denies obesity
Denies congenital heart defects
Denies family members with risk factors such as: morbidity, mortality related to cardiovascular system, and sudden death
Personal and Social History
Denies employment
Denies tobacco use
Healthy nutritional status
Usual diet consist of a large amount of carbs and sugars, low
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
Sleep more than usual
Symptoms do not fluctuate
This indicates that patient may have RBC problem
How-
Stated “I have no idea how I am still tired after the amount of sleep I get.”
Full-time student
Patient is in no pain, rather apathetic about symptoms
Social support from friends and family
Why-
Assumes it is a blood or hormone problem
No methods of treatment noted
Past Medical History-
Denies cardiac surgery or hospitalization for cardiac evaluation or disorder
Denies rhythm disorder
Denies acute rheumatic fever, unexplained fever, swollen joints, inflammatory rheumatism, Sydenham chorea (St. Vitus dance), abdominal pain, skin rash, or nodules
Hypertension noted, denies bleeding disorder, hyperlipidemia, diabetes, thyroid dysfunction, coronary artery disease, obesity, and congenital heart defect
Family History-
Denies long QT syndrome
Denies diabetes
Denies heart disease
Denies dyslipidemia
Hypertension noted
Denies obesity
Denies congenital heart defects
Denies family members with risk factors such as: morbidity, mortality related to cardiovascular system, and sudden death
Personal and Social History
Denies employment
Denies tobacco use
Healthy nutritional status
Usual diet consist of a large amount of carbs and sugars, low