l. Health History

Reason for Visit: “I cannot catch my breath and my temperature was high.”

Client Profile:

Gloria is a 59-year-old Caucasian female who arrived in the Emergency Department via ambulance.

Gloria reports she has had shortness of breath for the last 24 hours and that it has gotten worst over the past few hours. She also states that she is cold and has as productive cough, dyspnea, diaphoresis, and fatigue.

Gloria explained to the ED nurse that she should have gone to see the doctor three days ago for her cough but that she was so tired, that she just couldn’t get out of her chair.

Gloria continues to tell the nurse that when she couldn’t catch her breath and that when she took her temperature it was 38.5C (101.3F) she called her niece who came over and called the ambulance.

Gloria has a past medical history of Diabetes Mellites, type II- controlled by diet, Hypertension, Congestive Obstructive Pulmonary Disease (COPD), Anxiety and is post-menopausal – last menses was 7 years ago. Gloria currently lives alone in her own home, and since her company moved out of state, she has worked from home for the last 6 months.

Gloria states that she quit smoking 3 years ago when she was diagnosed with COPD. She lives near her niece, has no know allergies and most of the time she has a good appetite and enjoys cooking.

Gloria’s current medications include: Albuterol inhaler as needed, roflumilast mcg tablet per day, fluticasone propionate 220 mcg twice daily, Lisinopril 20 mg daily, Amlodipine 5 mg. daily and Sertraline HCL 50 mg orally once a day

II. Physical Assessment: 

Vital Signs: T: 38.8; P: 110; RR: 24; BP: 148/96; Oxygen Sat. 88% on room air

Gloria appears her stated age, she appears ill and somewhat anxious. She appears well nourished, has good personal hygiene, and walks with a smooth gait. Ms. Jones is alert and oriented to person, place, time, and situation. Her head is round and proportional for her body size. Ms. Jones’ hair is brown and thick with no evidence of alopecia. Her pupils are round and react to light equally and quickly, her scleral is white and she has no signs of redness or jaundice. Radial pulses and pedal pulses are 2+, and regular bilaterally, Ms. Jones has decreased breath sounds and coarse crackles in both lower lobes. Her nail beds are dusky on both upper and lower extremities, she has a productive cough that is producing thick yellow sputum. Her abdomen is soft and has bowel sounds in all 4 quadrants.  Ms. Jones follows commands and has an equal weak grasp strength in both her hands and is voiding clear yellow urine independently and is having no nausea or vomiting.

Please answer the following Case Study questions:

  1. Highlight relevant subjective information in yellow and objective information in green.
  2. Write out a symptom analysis for Gloria’s present illness. Choose one of the following mnemonics: PQRSTU, OLD CARTS or COLD SPA. Please label mnemonic.
  1. Are you missing any information? What further subjective questions would you want to ask Gloria? (Name at least 4 with rationales)
  1. Review the subjective and objective data and then cluster the data.  What do you think is going on with Gloria and why?
  1. Write a SOAP note using Subjective and Objective information only to summarize the key health history and physical assessment findings.

Use the format below:

SHealth History
 Biographical data:   
 Reason for seeking care: 
 Present health or History of present Illness: 
 Past Medical History:   
 Last menstrual period:   
 Family History:   
 Social history:   
 Nutritional Habits:    
OPhysical Exam
 Vital Signs:   
 General Survey:    
 Thorax and Lungs:   

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