Nursing assignment

65 years old female . Height 5’5” (165 cm) 126.0 lb (57.3 kg) Reason for encounter Trouble sleeping. Location outpatient clinic with x-ray, ECH and laboratory capabilities.

Key points – Change wording a little ·

Visual: anxious- looking, attentive alert, well dressed, seated on table.

Skin: palms moist.

Questions – How can I help you today?

I am having trouble sleeping, and I feel so tired during the day. I came to see if you could give me something to help me sleep better.

Question: If your problem falling asleep or awakening early?

Both actually. Can you prescribe a sleep pill?

Question: how long does it take for you to fall asleep?

Highly variable.

Question: Do you have a comfortable bed?

Yes

Question: do you have trouble lying in one position comfortably?

Nope

Question: does your bed partner adversely affect your sleep?

Nope

Can you describe a typical night sleep?

When I was sleep normally. I would go to bed around 10-11pm, immediately fall asleep within minutes and would wake up around 7 am. I slept straight through. Now I try to go to bed and toss and turn for an hour, sometimes two. Then sometime wake up at 2-3 am for no good reason that I can tell, and trouble getting back to sleep. That’s been going on for the last 3 or 4 months.

Question- If you wake in the middle of night, are you able to fall asleep again?

Not always, but mostly I do eventually. but it takes a while.

On average how many hours per night do you sleep?

That’s all over the map these days.

Are there any life events that have affected your sleep?

Not that I can think of.

Has anyone ever told you that you stop breathing or choke while you are sleeping?

No.

What do you do when you can’t fall asleep?

I just try to get up and do some housework and then go back to bed a bit later.

Do you take anything to help you sleep?

No, but I am hoping you can give me something for it.

How often and at what times do you wake up at night?

It varies. I don’t always look at the clock and I have not been keeping detailed track of how often. I guess every 2 to 3 hours.

Question: Why do you wake up?

I have no idea I just do.

Question: Do you awaken at night short of breath or night, cough?

No.

Describe your activities shortly before bedtime?

I read a little to wind down. I try not to watch TV ot get in front or get in front of a brightly- lit screen.

Question- is your bedroom quiet and dark?- Yes

Question:-how does the nights sleep affect your day?

I feel tired all day when I don’t get good sleep.

Question- Do you nap during the day?

Never, but I am really tired.

Do you snore?

No.

Have you been more irritable or angry lately?

Ans No

Can you tell ne about any current or past medical history?

I havnet had any, at least up to when all this started. I have been very lucky.

Question:any mental health problems? ---No

Question-

Do you have high BP?

Nope

Do you have high cholesterol?

No

Do you have heart disease and/or have you ever had a heart attack?

No

Do you have Diabetes?

No

Any previous medical, surgical or dental procedures?

Uh..no.

Question: have you ever been hospitalized?

Answer: yes, for the birth of my two children.

Question: have you had any significant traumatic injuries or accidents?

Nope

Have you fallen ? no

Are you taking any prescription meds?

Nope

Are you taing any over the counter or herbal medications?

I am still taking a multivitamins and calcium daily.

Do you have any allergies?

No.

When was your last physical?

I think about a year ago. You could check chart.

Are you immunization up to date ?

Yes, I took my flu shot about a year ago now and I also had my covid and booster.

Have you had DTP vaccine?

I had my tetanus shot 10 years ago.

Have you recently traveled? where did you go?

I have not travelled recently.

Have you ever lived in homeless shelter?

Nope.

Do you have abdominal bloating, back pain, weight gain or mood change a few days before your period starts?

I don’t have a period anymore.

Tell me about your health of your grandparents, parents and children?

Both my parents have passed. My grown kids are fine. You could have look at my chart . it has detaoiked info.

Where did you grow up?

In this country.

DO you drink alcohol?when did you last drink?

Last month.

Do you now or have ever smoked or chewed tobacco?

Way long ago in college a little bit.

How much do you smoke a day?

I don’t smoke.

Do you use injection drugs?

No

Do you have adequate housing?

Yeah.

how is your overall health?

It has been pretty good until I developed the sleep problem.

Have you been having fevers?

No

Do you have chills?

I haven’t had that problem>

How’s your appetite? Any recent changed?

I have been hungry all the time and I am definitely eating more lately.

Have you lost weight?

Yes, that really surprised me. I am not trying to lose weight, but it looks like I have lost 9 labs. I am not sure what is happening. Do I have cancer?

Have you been in a situation where you were sitting or lying still for a long time?

No

Do you give episodes of excessive sweating?

My hands feel sweaty a lot.

Do you have any trouble with hot or cold environments?

Actually, I am having more problems with heat when I am playing tennis.

What symptoms is most distressing you?

The not sleeping. I just would like to get some better sleep.

Tell me how that makes you feel?

I feel tired and well…. just not like myself.

Do you have any other symptoms or concerns we should discuss?

I feel a bit jittery or nervous and seems to be losing weight. I cant think of any other symptoms right this minute.

ROS

· General: denies weakness, fatigue, or fever. Reports 9 lbs weight loss. feels jittery and nervous.

· Skin: denies rashes, lumps, sores, itching, dryness, changes, etc.

· HEENT: Denies HA, head injury, dizziness, and lightheadedness. Eyes: Denies eye pain, redness, excessive tearing, double or blurred vision spots, flashing lights, and the use of eyeglasses or contact lenses.

· Ears: Denies ear pain, tinnitus, vertigo, discharge, and use of hearing aids.

· Nose and Sinuses: Denies frequent colds, nasal stuffiness, drainage, itching, nosebleeds, and sinus pain. Mouth and Throat: Denies bleeding gums, sore throat, dry mouth, hoarseness .

· Neck: Denies swollen glands, goiter, lumps, pain, or stiffness.

· Integumentary Breasts: Denies rashes, ulcerations, dryness, flaking, excessive sweating, and changes in moles. C/O Sweaty hands.

· Respiratory denies Not experiencing difficulty in breathing, coughing, or wheezing.Denies cough, dyspnea, increased sputum production, hemoptysis, snoring, and wheezing.

· Cardiovascular: Denies chest pain, tightness, or dyspnea. Reports on and off palpitations.

· Denies chest pain,orthopnea, PND, edema, intermittent claudication, leg cramps, and varicose veins. noted to have heart murmurs

· Gastrointestinal: Denies trouble swallowing, N/V, indigestion, abdominal pain, constipation, diarrhea, blood in stool, and hemorrhoids. Last BM yesterday, appearance usual for patient.

· Peripheral vascular:

· Urinary: Denies dysuria, urgency, nocturia, burning w/ urination, incontinence, flank pain, suprapubic pain, hernias, ulcerations, drainage, and hematuria. Has no concerns about STIs.

· Genital:

· Musculoskeletal: denies back, joint pain, or muscle stiffness.

· Psychiatric: Denies paresthesia, tremor, seizures, and gait/strength/balance/coordination changes. Denies problems with memory or speech.

· Neurological: Denies paresthesia, tremor, seizures, and changes in gait/strength/balance/coordination. Denies problems with memory or speech.

· Hematologic: Denies easy bruising or bleeding, pallor, and past transfusions.

· Endocrine: Pt.reported feeling hungry all the time, having sweaty hands, and having problems with heat when playing tennis.

· Allergic/Immunologic- No history of immune deficiency or immunomodulating drugs.

Physical Exam Vital Signs. Ht/Wt/BMI

SOAP OUTLINE

· General: General state of health, posture, motor activity and gait. Dress, grooming, hygiene. Odors of body or breath. Facial expression, manner, affect and reactions to people and things. Level of conscience.

· SKIN: Erythematous dry pruritic rash covering flexor surface of left elbow w/ superficial abrasions from scratching; no edema, drainage, or heat present. Otherwise, exposed skin is smooth and free of lesions, bruising, tattoos, and piercings. Several nevi were noted on the forearms and forehead. Hair thinning at crown and temples. No facial hair. Nails trimmed and in good condition.

· HEENT: Head: Normocephalic, atraumatic. No masses, lesions, or scalp tenderness.

·

· Eyes: Visual acuity not examined at this visit. Visual fields full by confrontation. Conjunctivae clear, sclera white. EOM intact, equal convergence, no nystagmus. Disc margins are sharp without hemorrhages or exudates, with no A-V nicking.

· Ears: Whisper test negative. Canals clear with average hair distribution, no erythema or edema. TM’s pearly gray landmarks and cones are in usual positions. Weber midline. AC > BC. Nose/Sinuses: Mucosa pink, moist without lesions or drainage. Nasal septum midline without perforation.

·

· Mouth/Throat: Lips and gums pink, moist without lesions. Teeth in good condition with evidence of cavity filling on bilateral lower molars. The tongue is pink and moist, midline without lesions. Salivary glands are non-palpable/non-tender. Uvula midline rises with vocalization. Oropharynx pink and moist, no exudate. Tonsils absent. Jaw opens and closes smoothly.

·

· Neck: Full ROM w/o pain. Trachea midline.

· Chest/Lungs: Thorax symmetric with good excursion. Rate regular and unlabored. No accessory muscle use. Lung sounds clear and equal bilat. Diaphragmatic expansion symmetrical. No chest wall lesions, masses, or tenderness. Resonant in all lung fields. Nail beds pink w/o clubbing.

· Heart/Peripheral Vascular: Regular rate/rhythm w/o clicks, gallops, rubs, S3, S4, Carotid upstrokes brisk pulses 2+ bilat w/o bruit. Noted with high BP.C/O chest pain 6/10 with walking and no pain at rest. Noted to have heart murmurs.

· Abdomen: Obese, soft, symmetrical, w/o masses, lesions, or hernia. Bowel sounds normoactive x4 quadrants. Resonant w/ gastric tympany. No tenderness or rigidity on light and deep palpation. No renal/aortic/iliac bruits. Liver edge is smooth and palpable, 1 cm below RCM. Spleen and kidneys not examined. No CVA tenderness.

· Genital:

· Musculoskeletal: Full active ROM of all joints w/o pain, swelling, or deformity. Strength 5+ throughout. No tremor. Gait smooth with increased side-to-side sway.

· Neurological: Right-hand dominant. Alert and cooperative. Thoughts are coherent and oriented to person, place, and time. Cranial nerves II-XII intact. Good muscle bulk and tone, strength 5/5 throughout. Rapid alternating movement of fingers performed w/o difficulty. Light touch, position, sense, and vibration intact. Patellar reflexes 2+ bilateral. Romberg negative.

· Psych: Affect bright and appropriate.

Work needed

· ASSESSMENT •

Primary Diagnosis

Hyperthyroidism___ICD 10

Differential diagnosis –differential diagnosis 

1. DX: Generalized anxiety disorder and sleep disorders: ____ ICD 10

2. DX:_ Major depressive disorder: ___ICD 10

3. DX: _brain neoplasm , benign or melignent._ICD 10

TEST—

CBC- NORMAL

CMP – NORMAL

12 LEAD EKG- NORMAL

TSH-0.02- suppressed below normal level.

FT4=2.8ELEVATED

FT3- 2.2 ELEVATED

THYROID STIMULATING IMMUNUGLOBILINS >2.0

THYROID SCAN-Increased update and distribution.

Treatment plan

Medication

Non-Medication Therapy

Patient Education

Follow up

HEALTH PROMOTION

Reference. ( 3 years okd references only)