Christy Mecher
Biographical Data
Name: Norma James Gender: Female Age: 65 years old
Race/Ethnicity: Caucasian Religion: Patient does not identify with specific religion
Marital Status: Widowed Occupation: Unemployed; Never worked outside home
Financial: Receives social security. $684 a month. Insurance: Basic Medicare
Family: Widow for the past 4 years. Married to Thomas for 41 years. 2 grown sons, Brian and
Thomas Jr. who live out of the state. She also has 3 grandchildren living out of state
Health History
Present Health Status:
Allergies (4 points)
Medication Penicillin; causes a rash
Food NKFA
Environmental NKEA
Other Patient states “no other known allergies”
Current Health Conditions (4 points)
Type 2 diabetes
Hypertension
Atrial fibrillation
Medications: (12) Dose and Route Why this patient takes the
Name Generic and Trade medication
Generic Name: Glipizide 10 mg PO bid Type 2 Diabetes; Used to control
Trade Name: Glucotrol blood sugar levels.
Generic Name: Captopril 50 mg PO bid ACE inhibitor; Used to treat high
Trade Name: Capoten blood pressure. (Hypertension)
Generic Name: Digoxin 125 mcg PO q day Atrial fibrillation
Trade Name: Capoten
Generic Name: Warfarin 5 mg PO q day To treat and prevent blood clots;
sodium Blood clots are a side effect of
Trade Name: Lanoxin digoxin.
1
, Christy Mecher
Past Medical and Surgical History:
Surgical Patient denies any surgical history.
Childhood Illness Patient states, “I had all those childhood illness, just
don’t remember when.”
Hospitalizations Patient denies ever being hospitalized. Patient states,
“I am not a big fan of hospitals.”
Immunizations Patient states she was immunized for Hepatitis B and
Tetanus “over 10 years ago.”
Last examinations Medical exam was 3 months ago.
Dental “a few years ago”
Eye: 6 months ago, she states “I have really noticed
that my eyes are changing.”
Accidents or Injuries Patient denies ever being treated for any accident or
injury, or having had surgery but shares, “I was in the
ER and I waited 4 hours and I left. That’s how I ended
up here.”
Obstetric History Two pregnancies, two vaginal births. Both children
are male and in their forties. Patient states, “They
were born at home. I am not a big fan of hospitals.”
Personal and Psychosocial History:
Family and Social Relationships Patient is a widow of four years, was previously
married for 41 years. Since her husband's death, is
mostly isolated. She has two adult sons with whom
she has limited contact; they live out of the state and
rarely call. There are only a few individuals whom
Mrs. James considers friends; she does not
2
, Christy Mecher
particularly like most people and prefers the company
of her six cats.
Diet Nutrition When you ask her about her food intake she tells you
“I purchase most of my food from my friend at the
convenience store. I like ramen noodles because
they are cheap and I also eat lot of my canned
spaghetti and soup. I am not a big fan of fruits and
vegetables!”
Functional Ability Patient can complete ADLs. Mrs. James does not
drive and relies on her friends, neighbors, or the city
bus for transportation. She lives near a grocery store
and prides herself on being able to get most things
she needs without any assistance.
Mental Health Patient is socially isolated. Patient spends most of
her time by herself. States, “Does not trust many
individuals, only has a few friends.” Patient seems
sad, upset and emotionally down about her current
situation.
Substance Use She smokes about 1/2 pack of cigarettes per day and
has been a smoker since she was in her twenties.
Pack years is about 20. She drinks alcohol “a couple
times a year, usually a glass of wine at a special
dinner.” Patient denies any illicit drug use.
Health Promotion Activities When asked about how she promotes health patient
states, “Who’s got the time or money for that. If it gets
bad enough, I will call my doctor. I have taken care of
myself, for my whole life, and since my husband died,
it is all on me!” Patient reports doing mainly sedentary
activities at home.
Environment Patient lives in a small one-story home in the
Southend. She lives close to the manufacturing area.
The Senior Center is close to the James home and
there is a grocery store within walking distance.
There is bus service to the area. Southend is the
poorer section of the Neighborhood, located close to
manufacturing plants at the south end of town. There
are homeless in the area and sidewalks are in poor
condition. There are only a few parks in the area and
some of them are in disrepair. There is a senior
center located nearby, within walking distance.
3
Biographical Data
Name: Norma James Gender: Female Age: 65 years old
Race/Ethnicity: Caucasian Religion: Patient does not identify with specific religion
Marital Status: Widowed Occupation: Unemployed; Never worked outside home
Financial: Receives social security. $684 a month. Insurance: Basic Medicare
Family: Widow for the past 4 years. Married to Thomas for 41 years. 2 grown sons, Brian and
Thomas Jr. who live out of the state. She also has 3 grandchildren living out of state
Health History
Present Health Status:
Allergies (4 points)
Medication Penicillin; causes a rash
Food NKFA
Environmental NKEA
Other Patient states “no other known allergies”
Current Health Conditions (4 points)
Type 2 diabetes
Hypertension
Atrial fibrillation
Medications: (12) Dose and Route Why this patient takes the
Name Generic and Trade medication
Generic Name: Glipizide 10 mg PO bid Type 2 Diabetes; Used to control
Trade Name: Glucotrol blood sugar levels.
Generic Name: Captopril 50 mg PO bid ACE inhibitor; Used to treat high
Trade Name: Capoten blood pressure. (Hypertension)
Generic Name: Digoxin 125 mcg PO q day Atrial fibrillation
Trade Name: Capoten
Generic Name: Warfarin 5 mg PO q day To treat and prevent blood clots;
sodium Blood clots are a side effect of
Trade Name: Lanoxin digoxin.
1
, Christy Mecher
Past Medical and Surgical History:
Surgical Patient denies any surgical history.
Childhood Illness Patient states, “I had all those childhood illness, just
don’t remember when.”
Hospitalizations Patient denies ever being hospitalized. Patient states,
“I am not a big fan of hospitals.”
Immunizations Patient states she was immunized for Hepatitis B and
Tetanus “over 10 years ago.”
Last examinations Medical exam was 3 months ago.
Dental “a few years ago”
Eye: 6 months ago, she states “I have really noticed
that my eyes are changing.”
Accidents or Injuries Patient denies ever being treated for any accident or
injury, or having had surgery but shares, “I was in the
ER and I waited 4 hours and I left. That’s how I ended
up here.”
Obstetric History Two pregnancies, two vaginal births. Both children
are male and in their forties. Patient states, “They
were born at home. I am not a big fan of hospitals.”
Personal and Psychosocial History:
Family and Social Relationships Patient is a widow of four years, was previously
married for 41 years. Since her husband's death, is
mostly isolated. She has two adult sons with whom
she has limited contact; they live out of the state and
rarely call. There are only a few individuals whom
Mrs. James considers friends; she does not
2
, Christy Mecher
particularly like most people and prefers the company
of her six cats.
Diet Nutrition When you ask her about her food intake she tells you
“I purchase most of my food from my friend at the
convenience store. I like ramen noodles because
they are cheap and I also eat lot of my canned
spaghetti and soup. I am not a big fan of fruits and
vegetables!”
Functional Ability Patient can complete ADLs. Mrs. James does not
drive and relies on her friends, neighbors, or the city
bus for transportation. She lives near a grocery store
and prides herself on being able to get most things
she needs without any assistance.
Mental Health Patient is socially isolated. Patient spends most of
her time by herself. States, “Does not trust many
individuals, only has a few friends.” Patient seems
sad, upset and emotionally down about her current
situation.
Substance Use She smokes about 1/2 pack of cigarettes per day and
has been a smoker since she was in her twenties.
Pack years is about 20. She drinks alcohol “a couple
times a year, usually a glass of wine at a special
dinner.” Patient denies any illicit drug use.
Health Promotion Activities When asked about how she promotes health patient
states, “Who’s got the time or money for that. If it gets
bad enough, I will call my doctor. I have taken care of
myself, for my whole life, and since my husband died,
it is all on me!” Patient reports doing mainly sedentary
activities at home.
Environment Patient lives in a small one-story home in the
Southend. She lives close to the manufacturing area.
The Senior Center is close to the James home and
there is a grocery store within walking distance.
There is bus service to the area. Southend is the
poorer section of the Neighborhood, located close to
manufacturing plants at the south end of town. There
are homeless in the area and sidewalks are in poor
condition. There are only a few parks in the area and
some of them are in disrepair. There is a senior
center located nearby, within walking distance.
3
