Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN: 9781451194524
Author: Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher: JONES+BARTLETT PUBLISHERS, INC.
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Personal Information

Name: Thomas Sykes

Gender: Male

Age: 17

Marital Status: Single

Weight: 240 pounds (108.86 kg)

Height: 5 ft. 11 in. (71 inches)

Occupation: High School Student

Address: New York, USA

Race: African American

Religion: Baptist

Allergies: None Known

Immunizations: Up to date

Major Support

Name: Keisha Sykes, age 31

Relationship: Sister

Phone: 577-666-7890

Attending Provider/Team: Susan Henretty, DNP, CRNP, PPCNP-BC

Past Medical History: Significant for chronic obesity and depression.

History of Present Illness: Thomas was recently discharged from an inpatient psychiatric program for suicidal ideation. He has undergone group therapy, individual therapy, and is taking an SSRI antidepressant medication (escitalopram). Upon discharge he was feeling somewhat less depressed. He is continuing in counseling and states it is helping. He is working on a healthy eating weight-loss plan and was instructed on keeping a food log.

Social History: Thomas lives with his sister, Keisha, and her 3-year-old son Torrey. Keisha has been Thomas’ legal guardian since their mother passed-away 10 years ago from complications associated with uncontrolled diabetes and obesity. Thomas’ father is not involved in his life. About a year ago, Keisha, Thomas, and Torrey moved for Keisha’s new job in the local battery plant. Her shifts rotate between days and evenings, requiring Thomas to care for Torrey when Keisha has to work the evening shift. Last year, Thomas was in his junior year of high school and had been planning to graduate with his

classmates, so the move for Keisha’s work has been difficult for him. Thomas did not make friends at his new school and spends most of his time alone playing video games or watching television with Torrey.

Primary Medical Diagnosis: Obesity and Depression

Surgeries/Procedures & Dates: No previous surgeries

Medications:

Drug: Escitalopram

Dosage: 10mg

Route: po

Frequency: Daily

Hours/Date of Administration: 9:00am

Discuss the clinical manifestations evidenced during your assessment. How would you explain these manifestations?

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