Biographical Data

a.Name - R. K.

b.Address - 1817 Reeds Run Rd, New Philadelphia Oh44663

c.Phone number – 330-663-6001

d.Primary language - English

e.Authorized representative - Self

f.Age and Date of Birth - 18yrs – 5/9/99

g.Place of Birth - Mombasa, Kenya

h.Gender - Female

i.Race - Black

j.Marital Status - Single

k.Ethnic/Cultural Origin - African

l.Education level - High School

m.Occupation/Professional - Student

n.Health insurance - Blue Cross/ Blue Shield

Chief Complaint: “My throat feels sore and scratchy, my nose has been running continuously and I have had a slight headache. I have had these symptoms for the last two days. Nothing seems to have brought these on, they just started. I would take some Tylenol to relieve the headache. The headache is dull at first but if I do not take anything it starts to throb. It gets to a level of 5 on a scale of 1-10. I thought that sleep would ease the headache but it does not. I use throat lozenges and some Vicks Vaporub but it seems like I am not getting any better. I think that I am having the flu and I would like to take care of it before it gets worse”

Patient is an18yr old female who came to the clinic this afternoon. She reports she has been having a runny nose and her throat feels scratchy and sore. She has also been experiencing headaches. The patient reports that she has been experiencing these symptoms for two days. Tylenol helps to relieve the headache and she takes throat lozenges and uses Vicks too. The worst of the headache is a number 5 on the numerical pain scale. Sleep does not seem to relieve any of the symptoms. The patient sounds nasally and would occasionally attempt to clear her throat. She reports that she feels she is getting worse and believes it could be the flu.

Past Medical History – Patient reports no major previous illnesses that she could remember but for reports of hospitalization when she was very young for infantile tuberculosis. She also reports to have been told to have suffered from chickenpox. Resident has no visible spots or marks on her body. She reports no surgeries, no pregnancies or psychiatric conditions. She reports no known allergies. Patient takes no prescription medication but for over the counter medication for relief of pain or discomfort. She takes 1000mg of Tylenol at least twice daily. She reports no use of herbal medication. Patient reports to have had all of her childhood immunizations and receives annual influenza shots. Patient reports to have had a full annual check-up visit nine months ago in May 2017 which also included regular blood work... Resident receives regular dental check-up twice annually and the last one was December 2017. Eye and hearing exam was last done in December 2017.

Family History - Patient reports that both her parents are still living, mother is healthy and father has hypertension (HTN). Paternal grandparents are living with paternal grandmother suffering from chronic kidney disease (CKD). Maternal grandmother is alive, suffering from hypertension and stroke as well as epileptic seizures. Maternal grandfather suffered a stroke. Mother’s siblings are alive with one sister suffering from uterine sarcoma and another sister from hypertension. Father’s siblings are alive; one brother suffering from HIV/AIDS and a sister has hypertension.

IV. Objective Data

General:

Skin:

HEENT & Sinuses:

Neck & Regional Lymph Nodes:

Breasts:

Lungs & Thorax:

Heart:

Gastrointestinal:

Genitourinary:

Extremities (Peripheral Vascular):

Musculoskeletal:

Neurological:

V. Assessment

A: Differential Diagnosis (include rationales and cite sources)

1.

2.

3.

B: Nursing Diagnosis

1.

C: Medical Diagnosis

VI. PLAN

A: Orders

1.Prescriptions with dosage, route, duration, and amount prescribed and if refills provided

2.Diagnostic testing

3.Problem oriented education

4.Health promotion/maintenance needs

B: Follow-up plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit — F/U in 2 weeks; plan to check annual labs on RTC (return to clinic).

VII. Nursing theory and application: Select a nursing theory and apply this to your patient’s plan and evaluation (brief statement).

VIII. Developmental stage: Identify the developmental state and provide rationales to support acquisition of skills in the stage (brief statement).

IX. Cultural characteristics, diversity, sensitivity, and ethical considerations

Discuss culturally diverse considerations you identified for this patient. Cultural diversity is a general term that can include gender, religious beliefs, culture, race, economic status, age, etc. Discuss one ethical standard relevant to the care of this patient.

X. Evaluation of care: Provide a brief statement sharing your thoughts about the visit and/or patient. Please share what you should have done differently.

References: Please include a minimum of three references. The reference list must be in APA format. All sources must be within 5 years of publication