History Physical Date Explained for Students (Easy Guide)

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Original Question

HISTORY & PHYSICAL Date/Time 04/01/20XX​ Hansel Jeong (pronouns he/him/his), 52 years old​ Chief Complaint: Fever, chills, dyspnea, and backache​ History of Present Illness: Hansel reports symptoms of fever, chills, shortness of breath, generalized weakness, and a backache. ​ Medical History: Right total knee replacement last week and received a blood transfusion during the hospital stay. Left total knee replacement 2 years ago with blood transfusion during that hospitalization. Otherwise, no significant history.​ Social History: Exercises one time per week; Work is desk job; Drinks 3-4 alcoholic drinks per week​ Family History: Family history of cancer​ Vital Signs: Blood pressure 100/64 mmHg, heart rate 112 bpm, respiratory rate 20 bpm, temperature 100.1 °F (38.4 °C) oral​ General Appearance: Client appears fatigued, with pallor​ Respiratory: Tachypnea noted​ Musculoskeletal: Tenderness to lower back noted​ Eyes: Scleral icterus present Laboratory Test Normal Range Results White Blood Cells 4,000-10,000 mm³â€‹ 8,000 mm³ Hemoglobin 11.5-14.5 g/dL 9.2 g/dL Mean Corpuscular Volume (MCV) 80-100 fL 84 fL Hematocrit 33-42% 28% Reticulocyte count 0.5%-1.5% 1.8% Coombs test negative positive Which 3 laboratory results should the nurse practitioner (NP) continue to monitor to evaluate if the client is improving? Select 3.​ Hemoglobin​ Hematocrit​ Reticulocyte count​ Mean corpuscular volume​ Coombs test White blood cells​

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