Geriatric History and Physical Essays

2919 Words Mar 12th, 2014 12 Pages
Geriatric History and Physical with Problem List and Plan
California State University, Dominguez Hills
School of Nursing

Health Assessment Lab

BSN 381L

General Patient Information
Client: 81-year-old Caucasian/Italian female
Source: Client, seems reliable
Marital status: Widower
Religion: Catholic

Occupation: House wife
Formal education: High school
Primary language: English, written and spoken
Secondary: None
Reason for Seeking Care: Shortness of breath and productive cough.
History of Present Illness: Recurrent episodes of shortness of breathe and productive cough since 2008. First episode occurred when she was in her early 80’s. She was awakened in the middle of the night with a very
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Son age 64, alive with history of Cancer / Hypertension
Daughter 57, alive with Multiple Sclerosis / Hypertension / Diverticulitis
Daughter 48, alive with Fibromyalgia
Son [adopted] age 46, alive with Hypertension
Son who passed away at age 6
General: Describes health status as “fair”. Height attained 5’2” weight 183 lbs. Patient states she has not experienced any changes in her weight over the past couple of months. Her ability to do activities has decreased since diagnosed with COPD and Congestive Heart Failure. She notices walking from the car into the house or activities such as watering the garden take more of an effort and her breathing becomes labored. Denies fever, chills, sweats, or night sweats unless exacerbation of respiratory problem. She states her living situation is “good”; she lives in a single story house on her own and able to perform activities of daily living.
Skin, hair and nails: Full of gray hair. Complains that skin is thin and fragile. Tears, bruises and bleeds with the “slightest” injury. Denies rashes, lesions, pruritus, sweating, or changes in hair or nails. Health Promotion: Uses sunscreen for protection of sunlight and tries to keep away from being in direct sunlight. Also takes multivitamin.
Head and neck: Complains of infrequent