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Patient case study with chief complaint cough - Essay Example

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Simmons c/o rt headache x1 week, started after work and felt behind the eye. Reports busy day at work, and standing up for approximately 6 hours. No report of injury. Rates pain 8/10 while walking or standing and is felt at the back of the eye. Relieved by 500mg of…
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Patient case study with chief complaint cough
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Patient case study with chief complaint cough

FAMILY HISTORY: Mother died at 84y/o (h/o HTN, Cataracts, RA, HF, Endometriosis), Father unknown age of death (h/o HF, HTN), Sister died at 48y/o from MI (h/o HTN, HF, smoker), Sister died at 54y/0 from HF (h/o HTN, HLD, HF, COPD, smoker), Brother died at 60y/o from lung CA (h/o HTN, Lung CA, smoker), Youngest Sister (h/o HTN).
SOCIAL HISTORY: Ms. Simmons was married for 5yrs, divorced for 22yrs, lives home with 36y/o daughter. Completed high school, 3 daughters, 2 grandchildren, and works 40 hours per week. Active in church, attends twice a week and street witness (door to door) Jehovah witness, refuses blood transfusions. Has health insurance at current job. Reports single, last sexual intercourse 22yrs ago, practicing celibacy, heterosexual. Likes to go out to dinner with family and friends, reading, and watching movies.
NUTRITION: (24 hour recall) Breakfast (today)-2donuts and white milk, Dinner-chicken salad sandwich, slice of cake, coke cola, Lunch-Chinese chicken w/egg roll, coke cola, 1 bottle water, Snack-chicken salad croissant, 1 decaf coffee, Breakfast (yesterday)-McDonald’s hash brown, sausage biscuit, orange juice.
General: Ms. Simmons has pleasant mood, sitting in chair w/arms folded in front of body, AAOx3, NAD noted, no c/o pain at present. She is dressed appropriately, w/good hygiene, well developed, and well ... Read More
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