Subjective and Objective Data and Assessment on a Patient - Essay Example

1. Record in a narrative format your subjective data findings from your client’s biographical data

Mr. A is 56 years of age and has a history of distant stroke and Atrial fibrillation. He presented two complaints stating “ I have been having this cough for several days now” and “my eyes are in pain”.

History of Present Illness (HPI)

1. Cough- The patient has had a history of COPD with a history of smoking 3-4 packs each day. Increase in sputum production, wheezing, and dyspnea. No fever or hemoptysis has been noted and the sputum looks clear.
2. Visual- history of both hypertensive and atherosclerotic cerebrovascular disease (Welber & Kelley, 2004).

2: Record in a narrative format your subjective data findings from your client for general status

PMH: -ETT 6/95 5 min HR 133 demonstrated 2mm upsloping ST depression with entering and anthropical carotid stenosis (Welber, Kelley & Sprengel, 2004).

-Seizure disorder but the patient states “I cannot recall evaluation details or my last episode”.

PSH:  -Removal and placement of cataract s/p on right

-R orchiectomy at 6 years of age due to a traumatic injury

-R CEA (Welber, Kelley & Sprengel, 2004).

Smoking:        3-4 packs each day

Social History: The patient is sexually active. He lives with his wife and his nephew. He has two children. He is a retired architect. He enjoys reading and walking.

Family History:           Father and Sister had CAD. At 5o years sister had CABG. Brother with DM. Father had multiple strokes. 

3. Record in a narrative format your subjective data findings from your client’s nutritional assessment

DATA:                        Na 137, Labs 2,19, CI 105, Glu 98, WBC 12.1, HCT 22.3, Pulse p72 L15 E2 B1, PLT 596, ALT 8, K 4.4

ASSESSMENT:            56 years old man with HTN, h/o PAF, CFA currently presents spatial difficulty and visual deficits.  He said, “I was having lunch when I had a sudden neurologic ailment”. Atrial fibrillation is consistent with embolic stroke. CT confirms infarction with the presence of a lesion in R PCA.

 Objective Data Collection

General Appearance and vital signs

For the last two years, Mr. A experienced PAF. In 2009 ECHO demonstrated NL EF and LA enlargement at 7cm with MR mildness. Until two months ago, he had been anticoagulated with Coumadin. He developed chronic iron deficiency anemia and GIB.

The patient was having his lunch yesterday when he experienced sudden sharp eye pain and his vision decreased. When he experienced the pain, he could not determine the telephone numbers well or see the wall clock clearly. The pain would be worse when coughing and was unrelieved by aspirin, Percocet, or Tylenol. No diplopia or blurred vision. He vomited and had nausea. The patient was not able to give his nephew directions to the hospital as he had difficulties in deciding whether to make left or right turns. Visual change and pain became worse at night.  No dizziness, dysarthria, palpitations, weakness, photophobia, CP.

Height and weight:     patient appeared to be 6"1, 257lbs

BMI:   16.2

DATA:                        AST 13, CO2 24.4, PT 12.5, INR 1.2, LDH 122, ALB 3.2, PTT 20.5, TB   0.4

ASSESSMENT:        Mr. A’s visual change could be a result of temporal arteritis. Although the patient has a temporal headache, there is no tenderness and the visual change is a bilateral loss that has occurred on the left visual area that is consistent with a cortical and not a retinal injury.