Candice Jeffries Age 36
Code Status – Full Admit Wt. 178.8 lbs (81.1 kg) BMI 28.9
Allergies: metronidazole, cephalosporin, hydrocodone
Thanks for seeing me today. I have gained so much weight, and there is something wrong. I am
usually a very healthy weight and exercise regularly. This is really bothering me. I've gained a
little over 30 lbs in the last three months.
NURSING ASSESSMENT & NOTES
7/10
1410
Neuro/Cognitive: Alert, oriented x 4. Speech clear. Hoarse, raspy
speech. Calm, cooperative. +fatigue.
Cardiovascular: S1 & S2 sounds present. HR regular, even.
Bradycardic. No edema. 3+ radial and pedal pulses.
Respiratory: Breathing nonlabored, regular. Lung sounds clear
bilaterally. No cough.
Gastrointestinal: BS present, hypoactive x 4 quadrants.
Abdomen soft, non-distended, non-tender. Last BM x 4 days ago.
Genitourinary: Urine yellow, concentrated per client description.
+frequency. States strong odor. States new onset of amenorrhea
for last three months.
Integumentary: Skin warm, dry. Client states sensation of feeling
cold all the time.
Pain: Rates 4/10 burning pain with voiding.
7/10
1620
Nursing Note: Dr. Stallons made aware of lab values. Additional
prescriptions placed. Telephone follow-up made with client
regarding lab values and medication prescriptions. Client
verbalizes understanding and states she will pick up medication at
pharmacy this evening.
7/26
0900
Nursing Note: Client returns for follow-up visit after initial
diagnosis of hypothyroidism. Reports taking levothyroxine
regularly. States she still experiences being cold “all the time.”
Client states she would like some additional information about the
disease.