Identifying Data - Assignment Example

Identifying Data The patient is a 50 year old female born in 13 March 1961 Kyoto Japan and moved to US 30 years ago. The patient is a mongoloid, is a widow and is a University graduate with a degree in special education. The patient works as a teacher and is currently holding a health and life insurance. The patient’s income is sufficient to take care of herself and her one son. The patient came to the hospital complaining of stomach ache and the presence of blood in her stool. According to the patient the pain in the stomach began one month ago on 3rd February 2012.

The patient said that initially the problem was mild with no stool in the blood. However, the problem got worse after 2 weeks and she started noticing blood in her stool. The location of the pain is in the upper abdomen and it gets worse after the patient takes heavy meals. Initially, the patient thought it was constipation and took mineral oil but the problems since persisted. The patient has missed work for 3 days when the problem became work and the patient currently avoids taking heavy meals.

The patient is afraid that she might have developed stomach ulcers. The medical history revealed that the patient is HIV positive and is currently taking antiretroviral. The patient has never had a major surgery. The patient has been treated once for depression when she was diagnosed with HIV after she was raped. The antiretroviral combination she is taking is EFV, TDF and FTC. The patient does not have any known allergies. The patient lives win Sunnyvale Texas with her 18 year old son in a rented apartment in the town.

She uses a lift to get to her apartment in fourth floor. The patient is currently on a light diet due to the stomach pains. The patient complains that her weight began to increase after she was placed on the antiretroviral therapy. The patient drinks around two liters of water every day and occasionally drinks soda. The patient goes for long call twice everyday in the morning and late into the night and says that she experiences pain. The patient experiences normal short calls at least three times daily.

Her ADL includes waking at 6: 30 am in the morning and prepares breakfast before driving to school. The patient has a house help who comes daily to do the cleaning of the house, dishes and laundry. The patient is able to do her own shopping, has no problem making phone calls and drives herself around. The patient also handles her own finances. The patient lives with her son and makes most of the decisions after consulting with her son. The patient revealed that her son has been greatly disturbed by her current illness.

Her memory, speech, judgment and senses are normal. The patient sleeps for at least 8 hours and does not use any sleeping aid. The patient sleeps in a single pillow. The patient goes for a jog twice every week. The patient loves reading and has only travelled once to Japan. The patient goes to Pap smear and mammogram after every three months. The patient goes to Yoga once every week for stress management. The patient is sexually inactive and does not use any recreational drugs, coffee or tobacco.

Review of System – Ask client about the following. Write your clients’ remarks in the box for each system General The client weighed 87Kgs and stated that she did not experience, fatigue, weakness or fevers. Skin Rash, lumps, sores, itching, dryness, color change, ? in hair/nails, change in color or size of moles Head Headache, head injury, dizziness, lightheadedness Eyes The patient does not put on every connective lenses and has never gone for an eye examination because she has never had any eyesight problem.

Ears The patient did not report any hearing problems or any infections of the ear and does not wear any hearing aids. Nose/ Sinuses The patient reported that she experiences colds occasionally and does not have allergies, sinus problems or hay fever. Throat The patient does not have any throat infections and does not wear any dentures. The last dental exam was 2 months prior to the interview. Neck The patient does not have goiter, swollen lumps on the neck or stiff neck. Breasts The patient did not report any swollen lumps on the breast or any unusual discharge from the breast.

Pulmonary The patient did not report any cough in the recent future Cardiac The patient did not report any cough or pain in the chest. The patient did not also report any discomfort, palpitations, dyspnea, orthopnea or edema. G/I The patient’s appetite has reduced due to the pain in the stomach. The patient has also been experiencing painful bowel movement and sometimes hematochezia and constipation. The patient does not have hemorrhoids. Urinary The patient does not experience nocturia or incontinence.

The patient has not had any history of kidney stones or kidney infection. G/U (General) The patient has not had sex since she was diagnosed with HIV and says she does not feel like having sex Male G/U Discharge from or sores on penis, testicular pain/masses Female G/U The patient first experienced her menses at the age of 13 years and the menses averagely lasted for 5 days. The patient has only had one pregnancy that led to a live birth through C-section. The patient has neither had an abortion or miscarriage.

The patient has not had post menopausal bleeding but experienced pain after intercourse in her early twenties. Peripheral Vascular The patient has never experienced any form of claudication, leg cramps, varicose veins, color changes in finger tips, or toes swelling with tenderness of redness. Musculo-skeletal The patient has never experienced muscle of joint pain or stiffness. Neuro The patient does not have a history of syncope, weakness seizures, paralysis, numbness of tingling Heme The patient does not have a history of anemia, bruising or bleeding or blood transfusion Endo The patient only experienced excessive sweating prior to being diagnosed with HIV.

The patient has not experienced any instances of polydipsia, polyphagia or polyuria. Psych The patient has been hospitalized for 3 days for depression but the patient was not suicidal and was placed on therapy for 3 months immediately after being diagnosed with HIV.