Health History

Health History

An 80-year-old white Caucasian female was admitted to the unit this morning with complaints of pain related to Rheumatoid Arthritis. The patient complains of back pain and right hip pain. The patient reports that she has had a bilateral partial hip replacement 29 years ago. The patient has a past history of edema, chronic pain, hyperthyroidism, opioid dependency, GERD, and vitamin D Deficiency and has been admitted in the past for these reasons. She has no allergies, has full code status, and has no history of smoking or alcohol use. Her vital signs are as follows: BP- 140/90, P-80, R-20, T-102.3, SPO2-90.

Laboratory and Diagnostic Testing

The patient’s BUN, Hematocrit, Creatine, Hemoglobin, RBC, WBC, Calcium, LFT, Albumin and platelets were all abnormal. Normal range for BUN is 10-20. Her BUN level is 47, which is high and out of reference range. A high BUN value generally mean kidney injury or disease is present. (Perry & Potter). Normal creatinine range for men is 0.5-1.1. Her creatinine level is 6.2, which is too high. Elevated creatinine level signifies impaired kidney function or kidney disease. The lab value for her BUN and creatinine level supports her reported diagnosis of RA. Normal range for albumin is 3.5-5. Her albumin level is 3.3, which is too low. Hypoalbuminemia is a deficit of albumin in the blood. Normal hematocrit range for women is 37%-48%. Her hematocrit level is 24.5%, which is too low. Normal RBC range for women is 4.2-5.4 million. Her RBC level is 3.00 million, which is too low. If you have too few or abnormal RBC, or your hemoglobin is abnormal or low, the cells in your body will not get enough oxygen. Normal WBC range is 5000-10,000. Her WBC range is 14,400, which is too high. A high WBC level can indicate a sign of infection or inflammation within the body. The lab value for her WBC level supports her diagnosis of RA due to the disease’s autoimmune nature. Normal platelet count is 150,000-400,000. Her platelet count is 68,000, which is too low. A platelet counts of less than 150,000 is lower than normal. If platelet count falls below normal, that is an indication of thrombocytopenia. However, the risk for serious bleeding doesn’t occur until the count becomes very low—less than 10,000 or 20,000. Her Calcium level were 8.31 which is low. Normal Calcium levels are 8.60- 10.30. Her LFT results were 12 and the normal ranges are 13-39.

Collaborative Management

The patient is currently taking the following medications: cholecalciferol for vitamin D deficiency, heparin for prophylaxis, levothyroxine for thyroid hormone replacement, oxycodone for pain, pantoprazole for GERD, paroxetine for anxiety, atenolol for hypertension, hydrocodone-acetaminophen for pain, and abatacept for immune suppression and aiding in slowing the progress of the disease process of RA. The patient has no dietary restrictions and reports a good appetite. The patient uses a wheelchair for all ambulation and uses a cane for transfer. The physician has ordered the patient be seen by a physical therapist for help with maintaining flexibility in the joints, reducing pain, and aiding in mobility.


1) Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2017). Fundamentals of Nursing (9th ed.). St. Louis: Elsevier/Mosby.

2) Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis: Elsevier.

3) Edelman, C., & Kudzma, E. C. (2018). Health promotion: Throughout the life span. St. Louis, MO: Elsevier.


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