Documenting Subjective Information Case Study Nursing Essay Examples
CASE 1
Patient Information: A 36-year-old female
S.
CC: “Constantly feeling tired even after a period of rest.”
HPI: The patient present complains of persistent tiredness even after rest. The patient reports that she lacks energy every day after a day’s job, which began a few months ago but has progressively gotten worse. She reports missing several workdays due to a lack of energy even after showering and dressing for work. She reports sleeping more than eight hours a night while needing several naps throughout the day. She reports an uncomfortable buzzing sensation traveling from the neck down to the spine with what sounds to be a Lhermitte’s sign. Uses interferon to manage MS, CBD oil to help with energy without relief, and Cetirizine 10 mg PO daily to manage allergies(Documenting Subjective Information Case Study Nursing Essay Examples)
Current Medications:
Interferon to manage MS
CBD oil to help with energy without relief
Cetirizine 10 mg PO daily to manage allergies
Allergies: Nasal congestion.
PMx: Diagnosed with Multiple Sclerosis 3 years ago. Up to date with her pap smear. She goes for a monthly self-breast exam. Saw her dentist and eye doctor within the last year.(Documenting Subjective Information Case Study Nursing Essay Examples)
Soc Hx: Has a full-time job. Occasionally drinks wine during the weekend. Denies tobacco or illicit drug use.
Fam Hx: Married with two children. Her other has diabetes and has hypertension. Farther and siblings are alive and well. She has an aunt diagnosed with MS and is wheelchair-bound. (Documenting Subjective Information Case Study Nursing Essay Examples)
ROS:
GENERAL: Denies fever, chills, weight loss, or gain.
HEENT: Face symmetrical. PERRLA is normal. No retinal hemorrhages or exudates. Reports nasal congestion. Oral mucosa pink and moist
SKIN: Dry, warm, and intact
CARDIOVASCULAR: Heart rate bradycardic. No chest pain, chest pressure, or chest discomfort
RESPIRATORY: Regular breath. No pauses or extra beats.
NEUROLOGICAL: Reports nasal congestion. She denies loss of bowel or bladder.
MUSCULOSKELETAL: Normal muscle function. Muscle tone palpated. No fasciculation, tenderness or atrophy. Buzzing sensation in the neck down the spine.(Documenting Subjective Information Case Study Nursing Essay Examples)
HEMATOLOGIC: Conjunctivae rim pale.
LYMPHATICS: No lymphadenopathy.
PSYCHIATRIC: No depression or anxiety. No history of splenectomy.
ENDOCRINOLOGIC: No thyromegaly.
ALLERGIES: Nasal congestion.
CASE 2
Patient Information: A 35-year-old male
S.
CC: “Acute low back pain.”
HPI: The patient experienced an acute onset of low back pain radiating down the back of the left leg following yard work. The pain has worsened in intensity, and he is having difficulty bearing weight on the leg. The pain ease with Ibuprofen 800mg. Rates pain eight out of 10, described as sharp, lightening sensation. (Documenting Subjective Information Case Study Nursing Essay Examples)
Current Medications:
Ibuprofen 800 mg to manage the pain.
PMx: Denies hospitalizations or surgical history. He sees primary care provider when he has an acute issue.
Soc Hx: Works for IT department from home. Sits about 8 hours per day. Reports smoking a pack of cigarettes a day ten years but quit five years ago. Currently vapes daily. He reports one beer with dinner. Denies illicit drug use.
Fam Hx: He recently divorced and shared custody of three children. Denies family history of the spine or musculoskeletal diseases or malignancy.(Documenting Subjective Information Case Study Nursing Essay Examples)
Health promotion: No regular health maintenance. Runs for at least 30 minutes daily. Eats healthy.
ROS:
GENERAL: Denies fever, chills, weight loss, or weight gain.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rashes or bruising.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea.
NEUROLOGICAL: Denies headaches, dizziness. Severe pain with active movement. Minimal pain with passive motion. Denies loss of bowel or bladder or saddle anesthesia.
MUSCULOSKELETAL: Denies history of lower back pain or previous back injury.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy
PSYCHIATRIC: No depression or anxiety(Documenting Subjective Information Case Study Nursing Essay Examples)
ENDOCRINOLOGIC: ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No NKFDA
CASE 3
Patient Information: An 83-year-old female
S.
CC: “A productive cough.”
HPI: The patient presentsa productive cough for the last three weeks. She reports fever on and off. She has chest pain, which worsens at night. She has a mild sore throat and nasal congestion.
Current Medications:
Guaifenesin to relieve sore throat and nasal congestion.
Tylenol 500 mg PO daily to manage osteoarthritis.
Citalopram 10 mg PO daily to manage depression
Omeprazole 10 mg PO daily to manage GERD(Documenting Subjective Information Case Study Nursing Essay Examples)
Levothyroxine 88 mcg PO daily to manage hypothyroidism
Allergies: Allergy to PCN with the reaction of hives.
PMx: No history of asthma or any chronic lung diseases. Diagnosed with osteoarthritis. Reports depression and GERD. Reports hypothyroidism. Hospitalized for the birth of three children. Had right knee replacement two years ago
Soc Hx: She lives in a retirement community and uses a rolling walker for long-distance walking and a cane around the house. Denies recent travel. She denies smoking, alcohol, or illicit drug use.
Fam Hx: Her children live close by and help her with errands. All her children are alive and well, no one with similar symptoms.
Health promotion: Up to date on vaccines, including flu and pneumonia vaccine. She wears her mask when she goes out in public and maintains a physical distance of six feet while practicing good hand hygiene.
ROS:
GENERAL: Reports fever.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Mucous membranes moist. No tonsillar exudate, oropharynx clear. Nares patent with clear drainage. Reports sore throat and nasal congestion.(Documenting Subjective Information Case Study Nursing Essay Examples)
SKIN: No rashes or bruising.
CARDIOVASCULAR: Reports chest pain and discomfort.
RESPIRATORY: Reports excessive cough and occasional wheezing. Irregular heartbeats.
GASTROINTESTINAL: Denies nausea, vomiting, or diarrhea.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy
PSYCHIATRIC: Reports depression.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No asthma.
CASE 4
Patient Information: A 64-year-old
S.
CC: “fatigue.”
HPI: Routine evaluation. The patient complained of fatigue for the past three months. Reports no change in the diet or lifestyle.
Current Medications: Over-the-counter non-steroidal anti-inflammatory medication (NSAID).
Allergies: No history of allergies.
PMx: Denies any past medical history, surgical history, or hospitalizations.
Soc Hx: Retired post office employee. Denies smoking. Reports an occasional beer with friends. Consumes bee three times a day following retirement.(Documenting Subjective Information Case Study Nursing Essay Examples)
Fam Hx: Reports family history of diabetes, hypertension, cardiac disease, and colon cancer.
Health promotion: No regular health maintenance. Runs for at least 30 minutes daily. Eats healthy.
ROS:
GENERAL: Reports fatigue but denies fever or chills. 4-pound weight loss.
HEENT: Reports lightheadedness. Eyes: Denies changes in visual. Ears, Nose, Throat: Denies trouble swallowing.
SKIN: No rashes or bruising.
CARDIOVASCULAR: Denies chest pain. No palpitations. Chest pressure or chest discomfort.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: Denies nausea or vomiting. No abdominal pain.
GENITOURINARY: Denies urinary frequency, burning, or hematuria.
NEUROLOGICAL: Reports lightheadedness. Normal bowel movements. Dark bowel movement.
MUSCULOSKELETAL: No suprapubic or CVA tenderness.(Documenting Subjective Information Case Study Nursing Essay Examples)
HEMATOLOGIC: Paleness of conjunctivae and palmar pallor
LYMPHATICS: No lymphadenopathy or swelling.
PSYCHIATRIC: No depression or anxiety
ENDOCRINOLOGIC: Denies cold or heat intolerance. Denies sweating.
ALLERGIES: No NKFDA
CASE 5
Patient Information: A 19-year-old female
S.
CC: “headaches frequently.”
HPI: The patient is a 19-year-old presenting a frequent headache, which has become more debilitating recently. Headache episodes occur at least twice monthly and last for two days. The pain in the right temple or the back of the right eye spreads to the entire scalp for a few hours. The pain is sharp and throbbing. The patient reports severe nausea. Noise and movement aggravate the pain. The pain eases when sleeping in a dark, quiet room.(Documenting Subjective Information Case Study Nursing Essay Examples)
Current Medications: Naproxen and Acetaminophen to manage the pain.
Allergies: Reports no drug allergies but has seasonal and allergies to pet dander.
PMHx: Persistent headaches.(Documenting Subjective Information Case Study Nursing Essay Examples)
Soc Hx: Is sexually active uses condoms. Currently a freshman in college. Denies alcohol, illicit drug, and tobacco use.
Fam Hx: A thorough history reveals her mother suffers from migraines.
Health Promotion: Last health visit was over the summer, up to date on health maintenance for her age.
ROS:
GENERAL: She denies fever, chills, night sweats, or neck stiffness.
HEENT: Normocephalic Eyes: She denies visual changes other than photophobia. Normal visual acuity Ears, Nose, and Throat:Mucous membranes pink and dry.(Documenting Subjective Information Case Study Nursing Essay Examples)
SKIN: Warm and dry.
CARDIOVASCULAR: She denies chest pain, palpitations, or edema.
RESPIRATORY: Denies shortness of breath or cough.
GASTROINTESTINAL: She denies abdominal pain but reports some nausea and vomiting.
GENITOURINARY: Last menses four weeks ago.
NEUROLOGICAL: Reports headaches.(Documenting Subjective Information Case Study Nursing Essay Examples)
MUSCULOSKELETAL: Normal muscle tone.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: Reports thyroid enlargement. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: Reports adenopathy.
ALLERGIES: Reports no drug allergies but has seasonal and allergies to pet dander.
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