NSG6420 / NSG 6420: Practicum I Family Health - Adult and Gerontology Final Exam latest (2021|gradedA+)

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Name: A.P. Pt. Encounter Number: Date: 11/01/2017 Age: 47 Sex: Male SUBJECTIVE CC: “Here for a follow up; my insomnia is no better” HPI: Pleasant African American male presents to the office ... for routine follow up and with complaints of a insomnia not improving with prescription medication. He states he sleeps approximately 3­4 hours a night. He states he falls asleep 30 minutes after taking Ambien but wakes after 3 to 4 hours and cannot return to sleep. He states he is a veteran of the Iraq war and believes he is suffering from PTSD. He shares the traumatic events of which he was a part of and saw during his time as a Marine in Iraq. He admits to irritability with sweating at inappropriate times. He denies depression, suicidal or homicidal ideations. He wishes to be referred to psychology for an evaluation. Medications: Amlodipine 10mg by mouth every day for hypertension. Lisinopril 5mg by mouth every day for hypertension. Zolpidem 10 mg by mouth every night for insomnia. Sildenafil 100mg by mouth as needed 30 minutes prior to intercourse. PMH Allergies: Denies Medication Intolerances: Denies Chronic Illnesses/Major traumas Essential Hypertension Insomnia Erectile Dysfunction Hospitalizations/Surgeries Denies Family History Mother deceased; unknown cause. Father living; congestive heart failure. Brother living; hypertension. Sister living; no known issues. Social History Works as an electrician for power company; Iraq war veteran, Marine. Lives with wife; has no children. Denies illicit drug, tobacco, or alcohol use. Wears seatbelt. ROS General Positive for sleep disturbances. Negative for any weight change, fatigue, fever, chills, night sweats Cardiovascular Negative for chest pain, palpitations, PND, orthopnea, and edema Skin Negative for delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles Respiratory Negative for cough, wheezing, hemoptysis, dyspnea Eyes Negative for corrective lenses, blurring, and visual changes of any kind Gastrointestinal Negative for abdominal pain, N/V/D, ingestion, constipation, hepatitis, hemorrhoids, eating [Show More]

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