Mabel Johnson. latest
Mabel Johnson.
Anam
Maredia
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 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
10. 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 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 with GI bleed from Ibuprofen use, chronic kidney
disease, and hypertension.
,Mabel Johnson. latest
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 100000832558064 from CourseHero.com on 02-23-2022 12:18:30 GMT -06:00
, Mabel Johnson. latest
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 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.
Mabel Johnson.
Anam
Maredia
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 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
10. 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 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 with GI bleed from Ibuprofen use, chronic kidney
disease, and hypertension.
,Mabel Johnson. latest
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 100000832558064 from CourseHero.com on 02-23-2022 12:18:30 GMT -06:00
, Mabel Johnson. latest
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 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.
