NU610 health assessment. Unit 1 Case Study 1000w. due 3-13-22. 3 references. APA format cover page.

Running head: UNIT ONE CASE STUDIES 1

Unit One Case Studies: Subjective Data

Megan Powell

NU610-7A: Advanced Health Assessment

Dr. Jacqueline Rhoads

Herzing University

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UNIT ONE CASE STUDIES 2

Unit One Case Studies: Subjective Data

Five different case studies are presented, all with different scenarios. The subjective data

should be separated and listed below. Subjective data is anything the patient says such as chief

complaint, history of present illness, past medical history, allergy identification, medication

reconciliation, social history, family history, health promotion, and review of systems (signs and

symptoms).

Case Study #1

Subjective Data

● Chief complaint: Routine physical examination

● History of present illness: Denies any present illness or symptoms. However, he states he

has some visual changes when reading up close. He also reports increased thirst and

urination.

● Past medical history: The patient notes he has hypertension but denies any other

significant medical history.

● Allergy identification: Denies any seasonal or drug allergies.

● Medication reconciliation: The patient states he takes Tylenol as needed for pain and

takes chlorthalidone 25 mg PO daily to manage his hypertension.

● Social history: The patient denies any smoking, recreational drug use, and consumption

of alcohol. The patient states he monogamous and married without children. The patient’s

highest level of education is a high school diploma. The patient works in landscaping.

● Family history: The patient’s father died at the age of 73 due to a heart attack. The

patient’s mother and siblings have no known health problems.

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UNIT ONE CASE STUDIES 3

● Health promotion: The patient states that he does not exercise. The patient notes he has

not had a dental or eye exam for the past 2 years. The patient also notes he has not had his

blood pressure checked in the last 5 years.

● Review of systems: The patient denies fever, chills, weight loss, or weight gain. He

denies hearing changes, headaches, or dizziness. He also denies shortness of breath,

dyspnea on exertion, swelling, or chest pain. The patient reports daily bowel movement

and denies abdominal pain, nausea, vomiting, or changes in appetite. The patient also

denies any skin changes such as rashes or bug bites. Anxiety, depression, numbness, and

tingling were also denied by the patient.

Case Study #2

Subjective Data

● Chief complaint: Coughing and shortness of breath.

● History of present illness: The patient has a chronic cough but notes it has worsened over

the last 2 days. He also notes a color change in his sputum from white to green and states

an increased need for using his inhaler. The patient also states that he feels short of breath

when coughing which is productive.

● Past medical history: Hypertension, chronic bronchitis, peripheral vascular disease, and 2

hospital stays for pneumonia in the last 5 years.

● Allergy identification: Penicillin allergy which causes a rash.

● Medication reconciliation: The patient states he takes 5 mg PO daily, lisinopril 20 mg PO

daily, albuterol 180 mcg 2 puffs every 4 hours as needed for shortness of breath or cough,

and acetaminophen 650 mg PO as needed for pain.

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UNIT ONE CASE STUDIES 4

● Social history: The patient notes he has a history of smoking, 60-pack year, and

continues to smoke 2 packs of cigarettes per day. The patient notes roughly one beer per

week and denies illicit drug use. The patient works full time as an engineer.

● Family history: The patient’s deceased mother had a history of CVA, depression, and

Parkinson’s disease. The patient’s father, who is still living, has a history of COPD, CAD

status-post CABG, and type 2 diabetes mellitus. The patient also has a son with no health

issues.

● Health promotion: The patient reports eating a heart-healthy diet and annual visits.

● Review of systems: The patient denies fever, chest pain, or peripheral edema. He denies

nasal congestion, visual changes, and ear pain. No abdominal pain, nausea, vomiting,

dizziness, or weakness reported.

Case Study #3

Subjective Data

● Chief complaint: Left knee pain starting last night.

● History of present illness: The patient states the pain began suddenly and worsened in

severity in 3 hours’ time. The patient denies any systemic symptoms, prior episodes, falls,

or recent injuries. The patient does note that he consumed a large amount of wine with

dinner last night. Pain is rated 6/10 that is constant.

● Past medical history: Hypertension. The patient states he has had swelling in the big toe

that went away on its own in the past.

● Allergy identification: Percocet allergy resulting in urticaria.

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UNIT ONE CASE STUDIES 5

● Medication reconciliation: The patient takes hydrochlorothiazide 12.5 mg PO daily for

his hypertension. The patient stated he took Ibuprofen for the pain this morning with no

relief.

● Social history: The patient admits to alcohol consumption. The patient denies smoking

and any illicit drug use. The patient is currently not working.

● Family history: The patient denies any family history of joint or musculoskeletal issues.

● Health promotion: The patient reports eating a heart-healthy diet and annual visits.

● Review of systems: The patient denies fall, injury, and weight loss/gain.

Case Study #4

Subjective Data

● Chief complaint: 10 episodes of watery, non-bloody diarrhea today, 2 episodes of emesis

last night, abdominal cramping, generalized muscle aches and weakness, headache, and

low-grade fever.

● History of present illness: The patient states having 10 episodes of watery, non-bloody

diarrhea today with two episodes of emesis last night. She states she is able to tolerate

liquids today. The patient also reports intermittent 4/10 abdominal cramping pain with

generalized muscle aches and weakness. The patient also complains of a headache and

low-grade fever of 99.7 at home. The patient notes that all symptoms (except the emesis)

began this morning after returning from a weeklong family trip to Cancun yesterday.

● Past medical history: Denies medical history and surgical history.

● Allergy identification: Denies food, drug, and seasonal allergies.

● Medication reconciliation: The patient states she takes no medications. The patient did

state she took Pepto Bismol this morning with no relief.

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UNIT ONE CASE STUDIES 6

● Social history: The patient denies alcohol consumption. The patient also denies smoking

and any illicit drug use. The patient stated last menstrual cycle was 3 weeks ago and is

single and not currently sexually active. The patient works part-time at a community

college.

● Family history: The patient states her son had the same symptoms that started this

morning.

● Health promotion: Last wellness exam was 2 years ago with cervical screening.

● Review of systems: The patient reports emesis, diarrhea, abdominal cramping, fever, and

headache.

Case Study #5

Subjective Data

● Chief complaint: Concerns about a mole on the face.

● History of present illness: The patient states the mole has been there for years and is not

reporting any symptoms. The patient’s wife is concerned and wants the mole checked for

abnormalities.

● Past medical history: Denies medical history and surgical history.

● Allergy identification: Denies food, drug, and seasonal allergies.

● Medication reconciliation: The patient states she takes no medications.

● Social history: The patient denies alcohol consumption. The patient also denies smoking

and any illicit drug use. The patient is married. The patient works as a librarian at a local

school.

● Family history: The patient states she has no family history of skin cancer.

● Health promotion: Had bloodwork, blood pressure check, and pap smear last year.

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UNIT ONE CASE STUDIES 7

● Review of systems: The patient denies fever, chills, weight loss, or weight gain. The

patient denies any drainage, bleeding, itching, change in size/shape, or pain at the site of

the mole.

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