NUR 600 Assignment 2.1: Patient History
NUR 600 Assignment 2.1: Patient History
Chief complaint: “Lower abdominal pain.”
History of present illness: W.F. is a 28-year-old African American female client who presented to the ED with a complaint of lower abdominal pain. She reports that the lower abdominal pain began about eight days ago. The pain is in the lower abdomen bilaterally. She states that the pain is intermittent, lasting approximately 10 minutes per episode. She reports experiencing 2-4 pain episodes per day in the past week. The client describes the abdominal pain as moderate cramping but non-radiating. The abdominal pain is associated with abnormal vaginal discharge, which she described as mucoid and creamish with an unpleasant odor. She also mentioned that she has been experiencing some degree of pain during sexual intercourse in the past month.
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In the past three days, she has been experiencing some pain when passing urine, and she is concerned that she could have a urinary tract infection. The patient denies having vaginal itchiness or irregular menstrual periods. The abdominal pain is worsened by physical and sexual activity and has no relieving factors. The client reports taking Motrin 400 mg TDS to alleviate the abdominal pain, but it had no significant impact. She rates the abdominal pain as 3/10. The patient reports being sexually active with multiple sexual partners. She states that she has an IUD but does not always use condoms.
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Past medical and surgical history: The client has a medical history of Asthma, diagnosed at seven years. She uses Ventolin HFA during asthma attacks. She reports that the Asthma has been controlled, and the last attack was more than five years ago. She has been hospitalized twice at 8 and 14 years due to asthma exacerbations. The patient has a history of recurrent candidiasis infections, for which she uses OTC vaginal clotrimazole suppositories. She has no history of surgery.
Family history: The client’s maternal grandmother had Breast cancer and died at 83. Her paternal grandfather had Diabetes and died at 88 years due to kidney failure. Her parents and siblings have no chronic illnesses.
Personal social history: W.F. was brought up in Jackson County, TX, and currently lives in Anderson County, TX. She has a Diploma in marketing and works as a sales agent in a furniture store. She is single and has no children. The client admits to taking alcohol 4-5 beers on her off-days and smokes 1PPD, but she denies using illicit substances. Her hobbies include swimming and reading fictional novels. She sleeps 5-6 hours a day and has at least three meals per day. She gets most of her food from fast joints because she is usually too tired to prepare meals at home. Her physical exercise pattern includes swimming on weekends and walking to her job and back, which takes about 10 minutes. The client’s support system includes her best friend and her sister. She denies having any legal history.
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