How To Write A Nursing Case Study
Source and reliability: Patient reliable.
Chief complaint: “My left hip hurt.”
Present illness: Left hip started hurting since yesterday, it is constant pain. She rated 4/10. The pain feels dull that does not radiate to anywhere. The pain is aggravated by stationary sitting, and it is relieved by “up and moving around”. She has not taken anything for the left hip pain. She has no other associated functional inability related to her complaints. Able to perform activities of daily living without restriction. Patient expressed that she is not concerned about the left hip pain, …show more content…
Illicit drugs use: None
Childhood illness: Chickenpox, measles, whooping cough
Adult illnesses: Hypothyroid, arthritis in hands and back. HTN, hypochloremia, diabetes controlled with diet.
Surgical: Bilateral cataract surgery 2009, bilateral knee replacement 2014, hysterectomy (unknown year), appendix removal 1980, broken left ankle 1985, tubaligation with (unknown year).
OB/GYN: 2202. She has 2 living children, she had a set identical twins. One of the twin died in a car accident over 30 years ago. Menarche at age 13. She could not remember her last menses prior to hysterectomy. She is not sexually active, with no concerns of risks for HIV infection.
Health Maintenance: Immunization: yearly flu shot, Zostavax at the age of 60. She is unsure of her last Td booster. She has had PPSV23 and PCV 13 a year later. Dental exam and cleaning every 6 months, last exam and leaning were 3 months …show more content…
Pap smear is no longer recommended for screening since she is over 65 and with no known high risk for cervical cancer.
Family history: Father died at age of heart disease while in his 60’s, had history of diabetes. Mother died at age of 93 due to pneumonia.
She has one sister, who is living in the same town as her. She is relative healthy, no known chronic diseases. Another sister lives in another state who has history of leukemia.
Known family history of diabetes, heart disease, cancer,
Personal and Social History: She was born and raised in a small town northeastern Missouri. She finished high school and was married at age of 19. She worked on the assembly line (with repetitive motion) at the Lamberts manufacturing company and was retired there. The company is now closed. She has been living in surrounding small towns since she was married. She has two living children. Her husband past away in his 60’s from brain cancer. She has not been remarried. She receives retirement funds from her husband’s military benefit, and she is finically stable. Her children are married. Her son lives in a nearby small town and her daughter lives about 3 hours away in a different state. She has one sister that live close by. She goes to the same church with her sister. She has many friends. She is very involved in church activities, goes to church on Wednesdays and Sundays. She volunteers at the local church. She states “I like to keep myself busy”.