NURS 5643 Comprehensive Health Assessment: Patient Profile & History
Reason for Visit: The Chief Complaint (cc): “I have Psoriasis, and I am having a flare
with itching and burning pain.”
Date of History: On 9/9/23, the patient reported to a clinic setting on Day 3 of a Psoriasis
flare-up.
Patient Profile:
• Patient Initials: DH
• Age: 57
• Gender: F
• Pronouns: She/Her/Hers
• Marital Status: M
• Ethnicity/Country of Origin/Race: White/Non-Hispanic
• Language: English
• Education level: BS
• Religion (optional): Methodist
• Occupation: Physical Therapist
• Health insurance status: Insured; Private Pay- PPO
• Source of History and reliability of source: Patient, GCS 15; A&O x 4
Health Status or History of Present Illness (HPI):
The patient is a 56-year-old, well-nourished Caucasian, non-Hispanic female with a 12-year
history of Psoriasis and a strong family history of autoimmune, kidney, and gastrointestinal
diseases. She presents to this clinic after a “Psoriasis flare-up.”
The patient began experiencing symptoms about 3 days ago (9/6/23). At that time, she
experienced increasing bilateral leg pain and pruritis from her knees to ankles, and reports
symptoms do not radiate to other areas. The patient reports that she has been prescribed and
has routinely taken a topical cream (Zoryve - 0.3%), to control symptoms, but has
recently run out of the prescription (about two weeks ago). She reports when she uses the
cream consistently and as directed, her symptoms of Psoriasis improve, and her Psoriasis
remains under control. She reports her Dermatologist has been on vacation, and she has
been unable to get a refill.
For the past three days, the patient has been experiencing worsening Psoriasis symptoms.
She has many “raised, red, scaley patches of skin “on her bilateral lower extremities. Her
pain is now rated at 5/10, with a “burning” sensation aggravated by scratching and when
exposed to heat or when sweating with exercise. She says the pain is constant. The
symptoms are not relieved with OTC pain relief or other OTC anti-itch cortisone creams.
She says she gets mild relief with an Epsom salt bath and in her salt-water pool. The patient
reports, “The only thing that works is my prescription cream that I am now out of.” She
NURS 5643 Comprehensive Health Assessment: Patient Profile & History
, 2
states she does sometimes use Phototherapy for the treatment of her Psoriasis, but
according to the patient, she is unable to use the light treatments when she is in such a
“severe flare.”
The patient denies any other problems that need to be addressed at this time and is
requesting a refill on her topical Zoryve - 0.3% cream at this visit. The patient states she
is compliant with her medication regimen. She feels that she is healthy and has been
making significant improvements in weight loss, losing about 30 pounds in the last six
months after starting Ozempic and eating a healthy diet. She also states her mental
health has improved by attending weekly ALNON meetings due to stress from her
spouse, who she reports is a life-long alcoholic and is in and out of rehab multiple times
a month. She reports they have recently separated, and she now lives alone and has
fewer stressors with living apart from her spouse. She says her depression is well-
controlled on daily anti-depressant medication.
The patient has a history of reoccurring and frequent kidney and salivary stones. In
addition, she has an extensive GI history, including removing her large intestine. She
now has a J-Pouch instead of a large intestine due to severe UC. Because of the surgery,
she had been low on Vitamin B12 for some period due to malabsorption, which she says
caused her to develop paresthesia disorder of irreparable peripheral nerve damage with
mild distal numbness to bilateral fingertips. In addition, she has frequent bowel
movements, some of which can be loose. The patient was also genetically tested and
reported she has the MTMHR mutation, for which she frequently gets bloodwork to
monitor for low vitamin and folate levels and prescription vitamin replacement. She is
also currently on HRT, which she reports works well and controls all her previous post-
menopausal symptoms, including hot flashes and sweating.
She does not smoke, take illegal drugs, or drink alcoholic beverages. She denies being
sexually active. The patient wears corrective lenses to read and drive due to her
nearsighted diagnosis by her eye doctor. She is currently independent for all ADLs and
IADLs.
Past Medical History (PMH):
-Childhood Illnesses:
Measles – “ 5 t h disease” - age 7
Mumps - Negative
Rheumatic Fever – Negative
Polio – Negative
Rubella – Negative
Pertussis - Negati ve
Scarlet Fever - Negative
Chickenpox (varicella) - age 23
Frequent otitis media – Negative
• Others – Negative
NURS 5643 Comp Health History and Risk Assessment
Reason for Visit: The Chief Complaint (cc): “I have Psoriasis, and I am having a flare
with itching and burning pain.”
Date of History: On 9/9/23, the patient reported to a clinic setting on Day 3 of a Psoriasis
flare-up.
Patient Profile:
• Patient Initials: DH
• Age: 57
• Gender: F
• Pronouns: She/Her/Hers
• Marital Status: M
• Ethnicity/Country of Origin/Race: White/Non-Hispanic
• Language: English
• Education level: BS
• Religion (optional): Methodist
• Occupation: Physical Therapist
• Health insurance status: Insured; Private Pay- PPO
• Source of History and reliability of source: Patient, GCS 15; A&O x 4
Health Status or History of Present Illness (HPI):
The patient is a 56-year-old, well-nourished Caucasian, non-Hispanic female with a 12-year
history of Psoriasis and a strong family history of autoimmune, kidney, and gastrointestinal
diseases. She presents to this clinic after a “Psoriasis flare-up.”
The patient began experiencing symptoms about 3 days ago (9/6/23). At that time, she
experienced increasing bilateral leg pain and pruritis from her knees to ankles, and reports
symptoms do not radiate to other areas. The patient reports that she has been prescribed and
has routinely taken a topical cream (Zoryve - 0.3%), to control symptoms, but has
recently run out of the prescription (about two weeks ago). She reports when she uses the
cream consistently and as directed, her symptoms of Psoriasis improve, and her Psoriasis
remains under control. She reports her Dermatologist has been on vacation, and she has
been unable to get a refill.
For the past three days, the patient has been experiencing worsening Psoriasis symptoms.
She has many “raised, red, scaley patches of skin “on her bilateral lower extremities. Her
pain is now rated at 5/10, with a “burning” sensation aggravated by scratching and when
exposed to heat or when sweating with exercise. She says the pain is constant. The
symptoms are not relieved with OTC pain relief or other OTC anti-itch cortisone creams.
She says she gets mild relief with an Epsom salt bath and in her salt-water pool. The patient
reports, “The only thing that works is my prescription cream that I am now out of.” She
NURS 5643 Comprehensive Health Assessment: Patient Profile & History
, 2
states she does sometimes use Phototherapy for the treatment of her Psoriasis, but
according to the patient, she is unable to use the light treatments when she is in such a
“severe flare.”
The patient denies any other problems that need to be addressed at this time and is
requesting a refill on her topical Zoryve - 0.3% cream at this visit. The patient states she
is compliant with her medication regimen. She feels that she is healthy and has been
making significant improvements in weight loss, losing about 30 pounds in the last six
months after starting Ozempic and eating a healthy diet. She also states her mental
health has improved by attending weekly ALNON meetings due to stress from her
spouse, who she reports is a life-long alcoholic and is in and out of rehab multiple times
a month. She reports they have recently separated, and she now lives alone and has
fewer stressors with living apart from her spouse. She says her depression is well-
controlled on daily anti-depressant medication.
The patient has a history of reoccurring and frequent kidney and salivary stones. In
addition, she has an extensive GI history, including removing her large intestine. She
now has a J-Pouch instead of a large intestine due to severe UC. Because of the surgery,
she had been low on Vitamin B12 for some period due to malabsorption, which she says
caused her to develop paresthesia disorder of irreparable peripheral nerve damage with
mild distal numbness to bilateral fingertips. In addition, she has frequent bowel
movements, some of which can be loose. The patient was also genetically tested and
reported she has the MTMHR mutation, for which she frequently gets bloodwork to
monitor for low vitamin and folate levels and prescription vitamin replacement. She is
also currently on HRT, which she reports works well and controls all her previous post-
menopausal symptoms, including hot flashes and sweating.
She does not smoke, take illegal drugs, or drink alcoholic beverages. She denies being
sexually active. The patient wears corrective lenses to read and drive due to her
nearsighted diagnosis by her eye doctor. She is currently independent for all ADLs and
IADLs.
Past Medical History (PMH):
-Childhood Illnesses:
Measles – “ 5 t h disease” - age 7
Mumps - Negative
Rheumatic Fever – Negative
Polio – Negative
Rubella – Negative
Pertussis - Negati ve
Scarlet Fever - Negative
Chickenpox (varicella) - age 23
Frequent otitis media – Negative
• Others – Negative
NURS 5643 Comp Health History and Risk Assessment
