NURS 6152 B Section 200 Mabel Johnson (completed) latest spring 2021.
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NURS 6152 B
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NURS 6152 B
NURS 6152 B Section 200 Mabel Johnson (completed) latest spring 2021. NURS 6152 B Section 200 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 h...
nurs 6152 b section 200 mabel johnson completed latest spring 2021
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Section 200
• History (Subjective) (S)
• Identifying data (ID): Mabel Johnson, a 76-year-old
African American female that resides in an
apartment on the second floor.
• 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. “
• History of present illness (HPI)
• 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
10. Associated symptoms with the pain are
swelling in her knees and sometimes her finger
knuckles.
• 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.”
• 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.
• Allergies: Ms. Johnson denies allergies to
medication, food, pollens and pet dander
(environmental).
• Immunizations: Up to date
• Past medical history (PMH) –
• Past medical disorders/illnesses
Hypertension (for the
last 20 years) Chronic
Kidney Disease
Peptic Ulcer Disease with GI bleed from Ibuprofen
4 years ago.
• Past surgical history (PSH)
No past surgical history
This study source was downloaded by 100000840830055 from CourseHero.com on 02-26-2022 01:11:01 GMT -06:00
• Injuries/disabilities
Patient reports no injuries or disabilities.
• Other hospitalizations
Denies hospitalization.
• Childhood illnesses
Patient does not report any childhood illnesses.
• Recent health exams
Last physical was completed 9 months and 19 days
ago.
• Preventive health care
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