Documentation Essay


S – Subjective

Patient name – X

Date of service: 19/06/2016

Source: the patient is the source of information

History of present illness

The patient is alert and oriented to other people, place, and time.

Back pain: the patient complains of lower back pains. The patient has been having lower back pain for some time. For the past three days, she has been using a hired wheelchair around her household due to the pain. The condition worsens with lengthy sitting or walking and can be relieved by leaning forward. An aching becomes sharp with a particular movement. The pain also occasionally radiates down her legs.

Patient X is also feeling discomfort to the lower rib. The back and lower rib pains are felt concurrently.

The patient has chest pains while breathing and coughing

He also complains of diarrhea and nausea or vomiting. The patient has been having diarrhea for the past three days especially after having meals. The patient presumes she has gastroenteritis, an inflammation of the stomach. He complains of muscle aches, dehydration, stiff neck, and swollen joints.

Patient X also complains of lower abdominal pains, fever, loss of appetite, and frequent painful urination, for the past three days. The pain has been causing discomfort. Patient X is also complaining of severe headaches that prolong throughout the day. A headache has been consistent throughout the three days. In the process, patient x had used some painkillers to alleviate the pain.

He also reports a one-week history of a sore throat of seeing white pus although had no significant dyspnea.

SH: the patient has been smoking for over 25 years, 1pk/day. She denies alcohol use.

Hematopoietic: denies excess bleeding

The patient has also added some weight due to recent inactivity. Eyesight is okay with no indication of shortsightedness.

O – Objective

The patient looks tired, and her breathing is somewhat labored. Difficulty in breathing, and shortness of breath.

The patient appears stated age in some pain, but not acutely distressed.

Lymph nodes: non-tender, no palpable

Stethoscope to check irregular bubbling or crackling sounds that show presence of secretions

Lung sounds anterior are: rhonchi and wheezing throughout

Lung sounds posterior are: rhonchi and wheezing throughout

Heart sounds are regular and precise.

He has high fever, shaking chills, and sweating looking feeble and fatigued

A running nose with occasional coughs that produce phlegm. The abdomen is tender to touch.

The patient also shows signs of dehydration.

He appears well in no acute distress. T.97.9, P 80reg, RR 12, BP 140/86, Ht 67 in, Wt 195lbs, BMI-30

Skin: not pale, no rashes

CV: rhythm and rate are regular (RRR), (+) 2/6 systolic ejection murmur heard best at the LLSB and radiates to the apex. N0 S3 or S4.

Neck: No thyroid nodules

ABD: abdominal tenderness, no hepatosplenomegaly by palpation or percussion

EXT: no edema, 2+ posterior tibialis, and dorsal pedal

A – Assessment/Diagnosis

Pulse oximetry is measuring the oxygen concentration in the blood. BP- 120/80, T- 101.5, P- 102, R-20 O2 saturation 92% on room air.

Lung sounds and X-ray took show signs of pneumonia.

Blood tests to determine the infection and type of bacteria related to it.

Stool test to determine the organism causing diarrhea and nausea indicate food poisoning.

Sputum tests taken from a deep cough. Recent onset of a cough, most likely represents bronchitis convoluted by bronchospasm given acute onset, fever and exam findings of diffuse wheezes. Cognitive heart failure looks unlikely as one would expect edema, an S3, and an elevated JVP.

Fatigue may also be related to the patient’s weight. Hypothyroidism is probable especially due to her weight gain, though it could also be caused by recent inactivity.

P – Plan

Nebulizer treatments every four hours as patient needs it.

Prednisone every twelve hours, Accu-check every four hours, chest therapy is to be done post nebulizer treatments, Tylenol with codeine every six hours as needed for pain. Artery relaxers, Nitroglycerin under the tongue to help relax the arteries for blood to flow smoothly through the narrowed spaces. Acid-suppressing medications to limit the amount of acid in the stomach.

He requires rest in a dark, quiet room. Hot or cold compresses on the neck and head to deal with a headache. Massage and small amounts of caffeine. Ibuprofen (Advil and Motrin) to relieve a headache.

Use of ginger, black pepper, dandelion root, carom seeds, cardamom, and Indian Gooseberry are home remedies to alleviate stomach pains and loss of appetite.

Drinking gradually larger amounts of fluids to deal with vomiting and dehydration. Oral rehydration like Pedialyte to treat dehydration. Avoid foods that are hard to digest. Consume small meals throughout the day rather than three large meals. Eat slowly and rest after eating with the head elevated around 12 inches above the feet. Drink liquids between meals instead of during meals. Consume foods that are cold or at room temperature if hot or warm meals cause nausea. Eat when less nauseated.

Advised patient x to quite any substance related use e.g. smoking

Pulmonologist to see the patient