iHuman Week 4 - Jennifer Alberson, 65 year old female - CC: trouble sleeping

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Subjective Jennifer Alberson Chief complaint: trouble sleeping History of present Illness: Patient is a 65 year old female. Patient presents with complaints of trouble sleeping. Stared a couple m onth... s 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 This study source was downloaded by 100000838928381 from CourseHero.com on 07-10-2022 21:16:33 GMT -05:00 https://www.coursehero.com/file/71016159/ihuman-week-4docx/ iHuman Week 4 - Jennifer Alberson, 65 year old female - CC:trouble sleeping Surgical history: none Family history: grandmother had thyroid problems Social history: goes out with friends, walks daily, plays tennis ever weekend, retired Allergies: none Medications: calcium and multivitamin Objective: VS: height: 5’7” weight: 126 pounds oxygen stat: 94%, temperature is 99 degrees, BP 130/72, heart rate 102 respirations 14 Constitutional: alert and oriented X3 and age appropriate. no distress noted, non-toxic appearing. Head/ neck: normocephalic, full ROM in the neck. No facial swelling or erythematic. Denies pain in the neck. Anterior and posterior cervical lymph nodes are not swollen. Thyroid is enlarged EENT: Ears: TM’s are pearly grey bilaterally with visible landmarks and light reflex. Ear canals are patent. Eyes: PEERLA, sclera’s are white in color. Nose/Sinus: no sinus pain upon palpation, nostrils are patent with no erythema or drainage noted. Throat: no hoarseness or erythema. No bleeding or ulcers noted. Uvula with proper movement and no swelling. Lips are proper color with no swelling. Cardiac: tachycardia, No murmurs noted. Negative for BLE. No carotid bruit. Respiratory: Chest expansion is symmetrical. Lungs are clear to auscultation. Percussion presents a resonance is noted. Tactile fremitus noted bilaterally. GI: Abdomen is non-protuberant and soft with normoactive bowel sounds. Abdomen is nontender, and no masses or hepatosplenomegaly noted upon palpation. Normal tympanic percussion noted throughout the abdomen. [Show More]

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