Mabel Johnson
A. 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 se...
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 andexercise 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
10. Associated symptoms with the pain are swelling in her kneesand
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 3rd 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 withGI
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)
, 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
60. Pap smear in the past have been negative. Last pap smear was done
more than 5 years ago. Colonoscopy was done 4 yeargo, 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 dailyProtonix 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 herknee
pain, Ms. Johnson has trouble getting around. Her daughter helps her
out.
11. Diet/Nutrition:
Diet and nutrition has been adequate.
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