Geriatric History and Physical Essays

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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…show more content…
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 ROS 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
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