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Identifying Data - Assignment Example

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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,

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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

Summary

The paper dwells upon the illness of the particular patient. The patient came to the hospital complaining of stomach ache and the presence of blood in her stool. The patient said that, initially, the problem was mild with no stool in the blood. …
Identifying Data
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