, Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Ron Jackson is an 87-year-old Caucasian male with a medical history of hypertension and Alzheimer's disease who was
brought to the emergency department (ED) by paramedics for evaluation of hallucinations, increased agitation, and
aggressive behavior toward Shirley, his elderly wife. His daughter was visiting and witnessed Ron becoming angry for no
apparent reason, telling Shirley she had to leave the house. He then pushed her, causing her to fall to the ground.
Ron has become progressively more agitated the past year and was started on quetiapine. Shirley confirms that Ron
has been more verbally abusive the past week, believing that she divorced him and that she needs to get out of the house,
but no physical aggression took place until today. Ron currently complains of a headache and insists that he got this
because “the Koreans beat me up real good in the ambulance!”
Personal/Social History:
Ron lives at home with Shirley, his wife of 62 years and has three children. Ron is a Korean War veteran who saw active
duty and is a retired salesman. Because his wife has been struggling to care for him, his family is in the process of making
arrangements for him to reside at a local memory care unit.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
m
RELEVANT Data from Present Problem: Clinical Significance:
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RELEVANT Data from Social History: Clinical Significance:
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1. Identify the relationship between the PMH and home medications. Which medication treats which condition?
Draw a line to connect the PMH to the correct medication.
is
Past Medical History (PMH): Home Meds:
Hyperlipidemia Donepezil 10 mg PO at HS
Th
Hypertension Aspirin 325 mg PO daily
Alzheimer's disease Memantine 10 mg PO BID
Agitation/Delusions Simvastatin 20 mg PO HS
sh
Triamterene-HCTZ 75-50 mg PO daily
Quetiapine 50 mg PO BID
2. Is there a relationship between any problem in his past medical history and the present problem? If so,
describe.
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