Patient: Ronald Thompson DOB: 12/16/1958 Medical Diagnosis:

Patient: Ronald Thompson DOB: 12/16/1958 Medical Diagnosis: Atrial Fibrillation Gordon’s Functional Health Patterns Patient Assessment Findings Health Perception-Management “I have been healthy my entire life until this dizziness started one week ago.” Has not been to the physician in over 10 years. Medical History: none Surgical History: Tonsillectomy (1978) Social drinker, Non-smoker Medications: Motrin for pain PRN “I get headaches once in a while.” Nutritional-Metabolic Weight: 198 lbs; no recent change. Height: 6 feet Regular diet, good appetite Well-hydrated Well-groomed Skin: Bruise to right elbow from fall Mucous membranes: Pink and moist Temperature: 36.8â—¦ C Elimination BM soft and formed, 1 Q Day Clear light yellow urine “I have noticed that it is taking a lot longer to start peeing” Abdomen: Soft and non-tender Activity-Exercise BP: 142/87 Pulse:125 RR: 17 Lungs: Clear Heart: Irregular rate and rhythm “I get short of breath at the same time that it feels like my heart is beating really fast.” “I usually work out at the gym 2-3 times a week religiously, but I have stopped since the dizziness and shortness of breath started” No edema Pedal Pulses 2 , equal Sleep-Rest “I usually get 8-9 hours of sleep at night, but lately I SCIENCE HEALTH SCIENCE NURSING

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