02-14-23 CARE PLAN #2
Interview with patient: retired college basket coach. Religion catholic
What brought you here today? Patient stated “I was feeling extremely tired all the time and I could sleep all night” I was just thinking about everything bills and life.
Oriented and alert times -2-3
Low energy level –hypothyroidism (see the medical diagnosis attached)
Patient has neuropathy with a brace of right lower extremities. Patientsambulate with wheelchair for long distance and currently on PT (physical therapy).
Patient vital signs bp 137/68 p 60 R 20 temp 97.6 pain none/denied.
Pacemaker on left chest/
Patient has history of heart attack MI, depression, diabetes mellitus, Gerd.
Patient has good support system: 2 daughter and a sister.
Last bowel movement 02-13-23
