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 an
...
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.
4. Allergies: Ms. Johnson denies allergies to medication, food, pollens and pet dander (environmental).
5. Immunizations: Up to date
6. Past medical history (PMH) –
a. Past medical disorders/illnesses
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
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 ta....................................................continued
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