Geriatric History and Physical
Geriatric History and Physical with Problem List and Plan
California State University, Dominguez Hills
School of Nursing
Health Assessment Lab
BSN 381L
General Patient Information
Client: 81-year-old Caucasian/Italian female
Source: Client, seems reliable
Marital status: Widower
Religion: Catholic
Occupation: House wife
Formal education: High school
Primary language: English, written and spoken
Secondary: None
Reason for Seeking Care: Shortness of breath and productive cough.
History of Present Illness: Recurrent episodes of shortness of breathe and productive cough since 2008. First episode occurred when she was in her early 80’s. She was awakened in the middle of the night with a very painful right-sided chest pain and cough. There was no warning of a problem. She reports the pain was “tight and pounding”. The pain was a 10 on a numeric scale 0-10 lasting about 25 minutes. Patient states her cough worsens when walking long distances, especially without using her walker and her breathing becomes labored. She states her cough usually lasts about three days but has noticed it becoming more persistent and feels the need to cough up phlegm. She saw a physician for that episode. Diagnostic test confirmed a diagnosis of Chronic Obstructive Pulmonary Disease when she had her first episode of these symptoms. Her lung sounds presented with some wheezing on the upper lungs bilaterally, she had rapid shallow breathing with a respiration of 24. Upon walking long distances she becomes emotionally anxious; rest does not relieve the client’s pain immediately. She was treated with a breathing treatment and aspirin. She tries to limit walking long distances, if necessary she will depend on using her walker. She states her pain from walking is accompanied by dizziness, which limits her mobility and is controlled by taking her medication Meclizine. She had another episode two years ago when getting off an airplane returning from
California State University, Dominguez Hills
School of Nursing
Health Assessment Lab
BSN 381L
General Patient Information
Client: 81-year-old Caucasian/Italian female
Source: Client, seems reliable
Marital status: Widower
Religion: Catholic
Occupation: House wife
Formal education: High school
Primary language: English, written and spoken
Secondary: None
Reason for Seeking Care: Shortness of breath and productive cough.
History of Present Illness: Recurrent episodes of shortness of breathe and productive cough since 2008. First episode occurred when she was in her early 80’s. She was awakened in the middle of the night with a very painful right-sided chest pain and cough. There was no warning of a problem. She reports the pain was “tight and pounding”. The pain was a 10 on a numeric scale 0-10 lasting about 25 minutes. Patient states her cough worsens when walking long distances, especially without using her walker and her breathing becomes labored. She states her cough usually lasts about three days but has noticed it becoming more persistent and feels the need to cough up phlegm. She saw a physician for that episode. Diagnostic test confirmed a diagnosis of Chronic Obstructive Pulmonary Disease when she had her first episode of these symptoms. Her lung sounds presented with some wheezing on the upper lungs bilaterally, she had rapid shallow breathing with a respiration of 24. Upon walking long distances she becomes emotionally anxious; rest does not relieve the client’s pain immediately. She was treated with a breathing treatment and aspirin. She tries to limit walking long distances, if necessary she will depend on using her walker. She states her pain from walking is accompanied by dizziness, which limits her mobility and is controlled by taking her medication Meclizine. She had another episode two years ago when getting off an airplane returning from