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Patient assessment patient profile


Case Study: Patient Assessment Patient Profile: · Name: John Smith · Age: 68 · Gender: Male · Medical History: Hypertension, Type 2 Diabetes, Osteoarthritis · Current Medications: Lisinopril, Metformin, Ibuprofen · Chief Complaint: Dizziness and fatigue for the past week Head-to-Toe Assessment General Appearance: · Well-nourished, appears stated age, slightly diaphoretic · Vital signs: BP 150/90 mmHg, HR 78 bpm, RR 18 breaths/min, Temp 98.6°F Head and Neck: · Normocephalic, atraumatic · PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation) · No jugular venous distention · Carotid pulses strong and equal bilaterally Chest and Lungs: · Symmetrical expansion · Lung sounds clear bilaterally; no wheezes or crackles · No use of accessory muscles for breathing Cardiovascular: · Regular rhythm, no murmurs or gallops · Capillary refill < 2 seconds · Extremities warm, no edema Abdomen: · Soft, non-tender, non-distended · Bowel sounds present in all quadrants · No hepatosplenomegaly Musculoskeletal: · Full range of motion in all extremities, though slightly decreased in knees · No deformities noted · Strength 5/5 in all extremities Neurological: · Alert and oriented to person, place, and time · No signs of focal neurological deficits · Cranial nerves II-XII grossly intact Skin: Need Assignment Help?

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Other Subject: Patient assessment patient profile
Reference No:- TGS03460525

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