Semester 2 Medical Diagnosis List - Sample

Student name: CHharmane Sanchez Client initials: GP Date data gathered:

M male XXXX

Date of admission: Admitting diagnosis: Failure Age: 85

12 July 2009 to Thrive

Current/Past medical/surgical history Description of each Dx (cite reference)

Include relevant dates.
1. Hypertension Sustained elevation of systemic arterial blood pressure in adults,
exists when systolic BP is equal to or greater than 140mmhg or
diastolic BP is equal to or greater than 90mmhg (multiple
readings). Often classified as primary or secondary, it is a major
risk factor for cardiovascular disease, chronic kidney disease and
death. (Lewis, 2019 pg 791)
2. Paranoid Schizophrenia Paranoid schizophrenia is characterized by predominantly
positive symptoms of schizophrenia, including delusions and
hallucinations. These debilitating symptoms blur the line
between what is real and what isn’t, making it difficult for the
person to lead a typical life.
3. Hypothyroidism Hypothyroidism is a common condition where the thyroid doesn't
create and release enough thyroid hormone into your
bloodstream. This makes your metabolism slow down. Also
called underactive thyroid, hypothyroidism can make you feel
tired, gain weight and be unable to tolerate cold temperatures.
4. Dementia Dementia is a collection of symptoms caused by various
diseases affecting the brain. Cognitive functioning in multiple
areas declines progressively impairing memory, judgement,
reasoning and abilities to communicate, carry out purposeful
movement or recognize familiar objects or people. The most
common type of dementia is Alzheimer’s. (Lewis, 2019
pg1568)

5. Diabetes mellitus This represents a heterogeneous group of conditions that

used to occur predominantly in adults, but it is now more
frequently encountered in children and adolescents. Circulating
endogenous insulin is sufficient to prevent ketoacidosis
but is inadequate to prevent hyperglycemia in the
face of increased needs owing to tissue insensitivity
6. Anemia Anemia is present in adults if the hematocrit is below 41%
(hemoglobin less than 13.6 g/dL [135 g/L]) in males or
below 36% (hemoglobin less than 12 g/dL [120 g/L]) in
females. C

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