West Coast University | NURS 680 Advanced Assessment 680B week 3 62 year old female.

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West Coast University | NURS 680 Advanced Assessment 680B week 3 62 year old female.-Identifying data: Patient B DOB: 7/20/1958 MR# 00031222 Source and reliability of history: 62-year-old female,... reliable historian. Demographics: • Gender: Female • Age: 62 • Marital status: N/A • Ethnicity: N/A • Social/occupation: N/A S: Subjective A 62-year old female complains of pain over several finger joints over bilateral hands that is “getting worse” to the point that she is no longer able to work in her garden. CC: Complaints of pain to several finger joints to both hands that is progressively getting worse. HPI: Onset: When did the pain start? Location: Bilateral finger joints. Duration: How long does the pain last? Is the pain constant or does it come and go? Characteristic: Can you describe your pain? Sharp? Burning? Tingling? Dull? Aggravating factors: Is there anything that makes the pain worse? Relieving factors: Are you taking any pain medications? What are you doing to relieve your pain? Treatment: Are you currently taking any medications, even OTC? Applying ice or warm compresses? Severity: No longer able to work in her garden. PMH: • Childhood Illnesses: Did you have any childhood illnesses? • Surgical History: Any surgeries? • Hospitalizations/Accidents/Injuries: Have you had any hospitalizations, accidents, or injuries? • Transfusions: Any previous blood transfusions? Sexual history: • Number of sexual partners- How many sex partners have you had? • Sexual orientation – What is your sexual preference [Show More]

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