Nursing H&P Example

In: Science

Submitted By mweber3
Words 1344
Pages 6
CC: Pt feels “anxious about itchy and red rash” all over her body

HPI:
19 y/o female with a history of frequent UTIs. She began experiencing symptoms a few days ago that were similar to those of her previous UTIs. She went to her PCP and was prescribed sulfamethoxazole – trimethoprim DS 1 tablet twice/day. Today was the third day of taking the medication and she woke up and experiencing a “rash all over her body”. Her skin feels extremely itchy and she describes it as red. She tried lotion and diphenhydramine with no relief. She is very anxious about the rash. She says she feels like she has a fever but has no chills. She feels very tired and her throat feels scratchy. She does not have any associated headache, eye pain, vision changes, ear pain or loss of hearing. She is not experiencing any chest pain, palpations, SOB, cough, nausea, vomiting, or diarrhea.

Histories (Hx): Meds and Allergies: sulfamethoxazole – trimethoprim DS t tablet 2x/day for UTI symptoms, NKDA. I would ask “Are you taking any vitamins or supplements?”

Med Hx: Frequent UTIs; pt previously had heavy periods and bad cramping which has resolved over the last 2 years

Surgical Hx: none

Family Hx: Mother and father are in good health. No siblings. I would ask “Do your mother’s parents have any health conditions?” If there is a history of an illness, I would ask “What was the age that he/she was diagnosed?” I would also ask “Do you father’s parents have any health conditions?” If there is a history of an illness, I would ask “What was the age that he/she was diagnosed?”

Social Hx: Patient is in college. She has one roommate, Zelda. She is sexually active with her boyfriend, Gary, and they use condoms. She feels safe in her living situation and environments. I would ask “Have you had any recent travel?”

T/A/D (tobacco, alcohol, and drugs): denies…...

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