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
Denies limitation of movement, lumps or swelling in neck.
Eyes: States her vision is well when wearing corrective lenses. She has worn corrective lenses since age 42. Reports she is nearsighted. Denies redness, swelling, diplopia, blurred vision, excessive lacrimation, itching, pain, inflammation or discharge. No history of trauma or familial disease. Health Promotion: Last eye exam 2010. Wears UV sunglasses in bright sunlight. Leaves a light on at night in the house for safety in case she needs to get up to use the bathroom.
Ears: Hard to hear that has also come with age, having to repeat things and uses loud volume on the television. Denies having to wear a hearing aid. Denies ear infections, earaches, discharge or tinnitus. Health Promotion: Uses washcloth to cleanse ears following shower.
Nose and sinuses: Denies discharge, obstruction, allergy, or sinus problems. No change in sense of smell, trauma or epistaxis.
Mouth and Throat: Moist, pink and intact mucous membranes. Has rare sore throat. Does not wear upper or lower dentures. Denies hoarseness, dysphagia, bleeding gums, or dryness of mouth or tongue. No excessive salivation. No postnasal drainage, or voice changes reported. No change in sense of taste. Health Promotion: Sees dentist when experiencing problems. Brushes teeth 2-3 times daily, flosses once a week.
Breasts and Axillae: Denies lumps, pain, or discharge. Denies axillary