SUBJECTIVE DATA: (INFORMATION GIVEN BY MRS. RILEY) Mrs. Riley has a college education, two teenage children, and a husband on permanent disability resulting from alcohol induced cirrhosis. Mrs. Riley states she was diagnosed with a brain tumor 3 years ago, successfully treated with surgery, radiation and chemotherapy, now on maintenance dose of prednisone, which patient reports stimulates her appetite and has caused her to develop diabetes. Mrs. Riley takes metformin to reduce her blood sugar. She has basic understanding of side effects of medication by correctly verbalizing that this medication can suppress her appetite and also promotes weight loss. Patient reports eating a half box of low-fat cookies for a snack on last evening.
Patient realizes the need to lose weight but states it is difficult because she spends a great deal of time traveling from job site to job site, little time for exercise, works long hours, therefore, she and her husband eats out on a regular basis. She denies smoking or drinking, has few social events due to her husband’s illness. Mrs. Riley reports that food was her only pleasure and now feels deprived due to dietary restrictions. She also states that life would have been simpler if her husband had died last summer when he was so critically ill. The above is objective because this is information given to the medical care provider by the patient.
OBJECTIVE FINDINGS: (PHYSICAL EXAM ALONG WITH LAB RESULTS)
Mrs. Riley is a 43 year old married woman, 5 feet 2 inches/62 inches tall, weighs 236 pounds/107.2 kilograms, noted to be often smiling during the interview, presenting with newly diagnosed diabetes mellitus. Patient has elevated blood glucose, cholesterol and triglyceride levels. The above is objective data because it is factual and descriptive, that which can be seen or measured.
PHYSIOLOGIC CONCERNS: ( REFLECTING DERANGEMENTS OF BIOLOGIC FUNCTIONS) Newly diagnosed diabetes, obesity,...