Student Name: Poth, Jason K.

Date: 28 Oct 2011 Room Number: 222

Review of Systems Tool

Yes Yes Yes No No No Weight Loss or Gain Fatigue Weakness Yes Yes Yes No No No General Fever Chills Night Sweats Yes Yes Other: No No Malaise Change in Sleep Habits

Pt states not getting much sleep while in the hospital related to nursing interventions, but no prior changes.

Comments

Yes Yes

No No

Anemia Bruises Easily

Yes Yes

Hematology/Lymphatic No Bleeds Easily No Prior History

Yes Other:

No

Swollen Nodes

Patient has bruises around umbilicus at site of sub-q Fragmin injection sites. Bruises are dark purple in color and aprox. 3.8 cm in diameter.

Comments

Yes Yes Yes Yes

No No No No

Rashes Lesions Pruritis Change in Moles

Integumentary (Skin, Hair, Nails) Yes No Color Change Yes No Texture Change Yes No Unusual Growth Yes No Prior History

Yes Yes Yes Other:

No No No

Excessive Sweating Excessive Dryness Excessive Bruising

Comments

Patient appears to have age related weakening of the superficial vascular system. Dark purple bruises on the anterior aspect of both lower legs. Dark purple bruising noted on medial aspect of right fore arm. Patient doesn't recall how these happened.

Yes Yes Yes

No No No

Headaches Syncope Enlarged Lymph Nodes

Yes Yes Yes

Head and Neck No Dizziness No History of Trauma No Neck Stiffness

Yes No Loss of Consciousness Yes No Neck Pain Other: light headed

Patient has episodes of light headedness that is of short duration. This symptom started about 3 days ago.

Comments

Yes Yes Yes Yes

No No No No

Visual Acuity Double Vision Change in Appearance Use of Visual Aids

Yes Yes Yes Yes

No No No No

Eyes Blurring Light Sensitivity Change in Vision History of Trauma

Yes Yes Yes Other:

No No No

Discharge Redness Glaucoma

Comments

Student Name: Poth, Jason K.

Date: 28 Oct 2011 Room Number: 222

Yes Yes

No No

Hearing Loss Discharge

Yes Yes

No No

Ears Tinnitus Vertigo

Yes Other:

No

Pain

"Minor age-related hearing loss" noted by patient. Patient does not recall date of last hearing test.

Comments

Yes Yes Yes Other:

No No No

Discharge Bleeding Frequent Colds

Yes Yes Yes

No No No

Nose Pain Change in Smell Post-Nasal Drip

Yes Yes Yes

No No No

Obstruction Snoring Allergies

Patient blew her nose this morning and produced a bloody mucoid secretion. No active bleeding or discharge noted.

Comments

Yes Yes Yes Yes

No No No No

Hoarseness Bleeding of Gums Pain Difficulty Swallowing

Yes Yes Yes Yes

Throat and Mouth No Change in Voice No Dentition Problems No Change in Taste No Difficulty Speaking

Yes Yes Yes Other:

No No No

Frequent Sore Throat Lesions Bad Breath

Patient said, "My sense of taste has seemed to have decreased slightly over the years."

Comments

Yes Yes Yes Yes

No No No No

Enlarged Thyroid Cold Intolerance Polyuria Change in Shoe Size

Yes Yes Yes Yes

No No No No

Endocrine Thyroid Tenderness Weight Change Hair Distribution Changes Prior History

Yes Yes Yes Other:

No No No

Heat Intolerance Polydipsia Skin Striae

Patient has a history of hypothyroidism. She takes medicine to replace hormones. Skin striae present, related to previous childbearing and prior thyroid related weight gain.

Comments

Yes Yes

No No

Pain Rash

Yes Yes

No No

Breasts Lumps Nipple Discharge

Yes Other:

No

Swelling

Comments

Yes Yes Yes

No No No

Shortness of Breath Sputum Prior History

Yes Yes Other:

Pulmonary No Pain No Hemoptysis

Yes Yes

No No

Cough Difficulty Breathing

Patient is experiencing acute SOB related to bilateral pulmonary emboli. Patient placed on oxygen therapy and placed in semi-Fowlers position.

Comments

Student Name: Poth, Jason K.

Date: 28 Oct 2011 Room Number: 222

Yes Yes Yes Yes Other:

No No No No

Chest Pain/Discomfort Pallor Dyspnea Hypertension

Yes Yes Yes Yes

Cardiovascular No Palpitations No Cyanosis No Orthopnea No Varicose Veins

Yes Yes Yes Yes

No No No No

Changes in Skin Texture Changes in Skin Temperature Edema Prior History

Comments

Patient has a of hypertension that she takes medication to treat. Patient has spider veins bilatterally on both lower extremities. She has pain on right side of her chest with breathing and difficulty breathing. Patient is taking medication that helps relieve the pain of breathing.

Yes Yes Yes Yes

No No No No

Changes in Appetite Heartburn Hematemesis Prior History

Yes Yes Yes Other:

Gastrointestinal No Food Intolerance No Abdominal Pain No Change in Bowel Habits

Yes Yes Yes

No No No

Dysphagia Nausea/Vomiting Change in Stool

Comments

Patient claims nausea occuring for the last few days, she claims the medicine is helping. Patient has been constipated for 7 days, she is taking stool softeners and Miralax with no relief yet. Patient has a history of GERD that she treats with medicine.

Yes Yes Yes Yes Other:

No No No No

Dysuria Frequency Change in Urine Color Hesitancy

Yes Yes Yes Yes

No No No No

Urinary Flank/Suprapubic Pain Nocturia Polyuria Incontinence

Yes Yes Yes Yes

No No No No

Urgency Hematuria Decreased Stream Prior History

Comments

LMP: Yes Yes Yes Other:

No No No

Increased Flow Pruritis Dyspareunia

Patient has had a hysterectomy.

Yes Yes Yes Yes

Female Genitalia No Irregular Menses No Vaginal Discharge No STDs No Postcoital Bleeding

Yes Yes Yes Yes

No No No No

Dysmenorrhea Lesions Change in Libido Prior History

Comments

Yes Yes Yes

No No No

Impotence Change in Libido Prior History

N/A

Yes Yes Yes

Male Genitalia No Discharge No Pain No STDs

Yes Yes Other:

No No

Rash/Lesions Changes in Scrotum

Comments

Student Name: Poth, Jason K.

Date: 28 Oct 2011 Room Number: 222

Yes Yes Yes Other:

No No No

Joint Stiffness Swelling Weakness

Yes Yes Yes

Musculoskeletal No Joint Pain No Redness No Creptius

Yes Yes Yes

No No No

Restricted ROM Heat Prior History

Patient has had arthroscopy on left knee. Patient has arthritis. Pain is worse in cold, wet weather. She uses heat to reduce the pain. Pain in right leg related to DVT. Patient stated that current medication therapy alleviates this.

Comments

Yes Yes Yes Yes

No No No No

Seizures Headaches Vertigo Numbness/Tingling

Yes Yes Yes Other:

Neurological No Stroke No History of Head Injury No Tics/Tremors/Spasms

Yes Yes Yes

No No No

Fainting Dizziness Ataxia

Comments

Yes Yes Yes

No No No

Nervousness Problems with Memory Change in Sleep Pattern

Yes Yes Other:

Mental Status No Anxiety No Mood Changes

Yes Yes

No No

Depression Stress

Patient complains of laack of slepp related to nursing intervention.

Comments