NURS 6152 B

Anam Maredia

NURS 6152 B

Section 200 Mabel Johnson

• History (Subjective) (S)

1.Identifying data (ID): Mabel Johnson, a 76-year-old African

American female that resides in an apartment on the second floor.

2.Chief complaint (CC): “I am having pain in my knees and I am

ready to do something about it. That is why they sent me to you.My knees have been getting worse over the past couple of years.They hurt when I walk for more than a block and when I climb stairs. “ 3.History of present illness (HPI)

a.Analysis of symptom/complaint:

Ms. Mable Johnson complains of pain in her knees that stared about five years ago but has gotten worse over time. The location of her pain is inside her knees, and the pain in her right knee is worse. The pain in her right knee radiates down to her ankle. Ms.Johnson describes the pain in her knees as stiff and achy. They are stiff in the morning for about 15-20 minutes. Cold weather and exercise makes her knee pain worse. She hasn’t found anything that helps with the pain. Ms. Johnson states that her pain level is usually about a 4 or 5 out of 10, and sometimes it is a 7 or 8 out of

• Associated symptoms with the pain are swelling in her knees

and sometimes her finger knuckles.

b.Impact on lifestyle Ms. Johnson has trouble getting around due the pain in her knees.Ms. Johnson states, “I have to walk up the stairs to get to it. Thank goodness I don’t live on the 3 rd floor. It’s getting harder and harder to get up those stairs. My daughter usually has to come help me.” c.Include significant chronic health disorders that impact on the current chief complaint.Ms. Johnson has a past medical history of peptic ulcer disease with GI bleed from Ibuprofen use, chronic kidney disease, and hypertension.

4.Allergies: Ms. Johnson denies allergies to medication, food,

pollens and pet dander (environmental).

5.Immunizations: Up to date

6.Past medical history (PMH) – a.Past medical disorders/illnesses Hypertension (for the last 20 years) Chronic Kidney Disease Peptic Ulcer Disease with GI bleed from Ibuprofen 4 years ago.b.Past surgical history (PSH) No past surgical history This study source was downloaded by 100000838654923 from CourseHero.com on 03-08-2023 07:41:10 GMT -06:00

https://www.coursehero.com/collection/85000072/Mabel-Johnsondocx/

A CLAUSE IHUMAN REVIEW

c.Injuries/disabilities Patient reports no injuries or disabilities.d.Other hospitalizations Denies hospitalization.e.Childhood illnesses Patient does not report any childhood illnesses.f.Recent health exams Last physical was completed 9 months and 19 days ago.g.Preventive health care Ms. Mable refuses to get mammograms after she had one at age

• Pap smear in the past have been negative. Last pap smear

was done more than 5 years ago. Colonoscopy was done 4 year go, 2 hyperplastic polyps were removed.

h.OB/GYN: G6 P6, all children are living.

7.Medications:

Amlodipine 10 mg tab, 1 tab PO daily Lisinopril 10 mg tab, 1 tab PO daily Simvastatin 20 mg tab, 1 tab PO daily Hydrochlorothiazide 25 mg tab, 1 tab PO daily Protonix 40 mg tab, 1 tab PO daily Acetaminophen prn headaches or pain Multivitamin daily

8.Family history: (FH)

Mother- arthritis and obesity Father-unknown Sister- HTN

9.Behavioral History:

Denies tobacco, alcohol, recreational drugs use. Also, denies participating in any sexual practices.

10.Social History:

Lives alone in an apartment that is on the second floor. Due to her knee pain, Ms. Johnson has trouble getting around. Her daughter helps her out.

11.Diet/Nutrition:

Diet and nutrition has been adequate.

• Review of systems (ROS) – Do a complete ROS of all systems. Always on

every patient – episodic & complete physical exam.General: This study source was downloaded by 100000838654923 from CourseHero.com on 03-08-2023 07:41:10 GMT -06:00

https://www.coursehero.com/collection/85000072/Mabel-Johnsondocx/

Patient denies any recent weight changes, fever, or fatigue. Patient states, “because of my pain I am moving around less and I think that is making me weaker.

Skin:

Patient denies any itchy scalp, skin changes, moles, thinning hair. Patient states, “as I age my nails seem less strong.”

Head, Neck, Ears, Nose, Throat (HEENT):

Head:

Patient denies any headache, head injury, dizziness or lightheadedness.

Eyes:

Patient denies pain, redness, excessive tearing, double or blurred vision, sports, specks, flashing lights, glaucoma, and cataracts.

Ears:

Hearing good. Denies tinnitus, vertigo, earaches, infection, or discharge.

Neck:

Denies lumps, goiter, pain. Reports no swollen glands.

Throat:

Reports no bleeding gums, sore tongue, dry mouth, frequent sore throats, and hoarseness

Breast:

Patient denies lumps, goiter, pain, or discharge.

Respiratory:

Patient denies cough, wheezing, shortness of breath, or sputum production.

Cardiovascular:

Patient reports a history of high blood pressure since the last 20 years. Denies chest pain, pressure, palpitation, dizziness, orblue/cold fingers and toes.Patient is unaware of exercise intolerant due to no participation in exercise.

Gastrointestinal:

Patient denies nausea, vomiting, constipation, diarrhea, coffee grounds in vomit, dark tarry stool, bright red blood in stool, early satiety, or bloating. Denies jaundice, gallbladder or liver problems.

Urinary:

Patient denies frequency, incontinence, dysuria, hematuria, or recent flank pain.

Genital:

Patient denies vaginal discharge, itching, sores, lumps, sexually transmitted infections and treatments. G6 P6. Denies any sexual practices. This study source was downloaded by 100000838654923 from CourseHero.com on 03-08-2023 07:41:10 GMT -06:00

https://www.coursehero.com/collection/85000072/Mabel-Johnsondocx/

Musculoskeletal:

Patient reports bilateral knee pain. She describes the pain as stiff and achy which occurs in the mornings for 15-20 minutes. The pain in the right knee is worse compared to the left. The right knee pain radiates down to the ankle. Patient also reports swelling in both knees and occasional swelling in her finger knuckles.Patient also reports limited range of motion. Patient denies any systemic symptoms with the joint pain such as fever, chills, rash, anorexia, weight loss, or weakness. Patient also denies neck, lower back pain, muscle pain, or gout.Psychiatric Denies nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. Denies past counseling psycho- therapy, or psychiatric conditions Neurologic Patient denies changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, black-outs; weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles, tremors or other involuntary movements, or seizures.

Hematologic:

Denies anemia, easy bruising or bleeding, past transfusion, or transfusion reactions.

Endocrine:

Denies “thyroid trouble”, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size. Patient reports, “I do prefer summer over winter.”

• Physical Exam (Objective) (O)

1.Vital Signs:

Left Arm BP: 138/86

Pulse: 82 regular rhythm

Respiration 12 unlabored Temperature 98.6 F Weight is 184 lbs 2.General assessment – Ms. Johnson is alert and oriented to place, time, and situation. She communicates well and is a reliable historian. She is sitting quietly and appears in no obvious distress. Ms. Johnson appears to be her stated age.

3.Document physical examination findings of systems appropriate to chief complaint (include pertinent positive and negative findings Positive findings: This study source was downloaded by 100000838654923 from CourseHero.com on 03-08-2023 07:41:10 GMT -06:00

https://www.coursehero.com/collection/85000072/Mabel-Johnsondocx/