presentation
SunflowerYT
HealthHistoryExample-Copy1.docxRunning head: HEALTH HISTORY 1
HEALTH HISTORY 9
Health History
Aimely Novales
Miami Dade College
Benjamin Leon School of Nursing
NUR 3039
Professor Ana Espinosa
October 28th, 2021
Patient Demographics
N.P is a 23-year-old, white, American-Hispanic male. The patient is 6 feet and one inch tall and weighs 206 pounds. The patient and his twin sister were born at 34 of gestation. He lives in Miami, Florida.
Chief Complaint / Present Illness
N.P came today complaining of neck pain. He states, “my neck has been aching a lot since I was involved in a car accident one week ago.” The patient said that the pain comes whenever he makes a “solid movement.” On a scale of 0-10, the patient states the pain is a 7. He said that he had taken Tylenol 500 mg to ease the pain, but it aids for a minimum period. Also, the patient does not complain of any other symptoms like headache, nausea, and vomiting. Other than the pain, the patient states he is overall “healthy.”
Past Medical History
Patient N.P has a history of chickenpox, common cold, and otitis media during childhood. The patient was hospitalized once due to ear tube surgery at three years of age. The patient denies any current illness. Patient N.P has regular checkups every year and is sexually active. In 2020 the patient got tested for STI and tested negative. The patient states he tested positive for COVID-19 for about two months and presented with symptoms of a common cold. He has already tested negative. The patient claims all his vaccines are up to date, included the Flu shot this year in September.
Current Health Status
The patient N.P states his general health status is outstanding other than the neck pain since the automobile accident. He practices soccer as a hobby. There are no physical signs of trauma. His vital signs are respiratory rate 17, heart rate 64, and blood pressure 134/82.
Genogram
Grandfather (71)
Heart & Renal Failure
Grandmother (65)
Sleep Apnea
Smoker
Grandfather (67)
Grandmother (81)
Heart Failure
Aunt (44)
Mother (47)
Obesity
Uncle (54)
Father (59)
Diabetes Mellitus type I
Son (35)
Son (23)
Twin
Son (16)
N.P (23)
Key:
Deceased male
Deceased female
Living female
Living male
Family History
The patient has a family history of Diabetes Mellitus type I from his father, who is 59 years old. The patient’s mother is 47 years old and agonizes from obesity. His grandmother is 65 years old and suffers from sleep apnea, and smokes three cigarettes a day. The patient’s grandfather is deceased at 71 years old. He suffered from renal failure and heart failure. In addition, patient N.P has three brothers with no medical illness, aged as follows: 35 years old, 16 years old, and a twin brother.
Personal & Social History
Patient N.P was born at Mount Sinai in Florida. Both his parents traveled from Cuba when they were younger. He is currently in a connection and lives with his parents. The patient works as a supervisor at Amazon. The patient is open to physical threats like falling, back issues, and objects falling onto him at his job. He finalized high school and is presently applying to Art School. The patient has regular stressors at work.
Review of Systems
Skin, Hair, and Nails: there is no bruising, rashes, or discolorations of the skin. No hair loss was reported nor noted. Color is consistent with ethnicity.
Head, Eyes, Ears, Nose, Throat (HEENT): the head is normocephalic with no lesions or masses noted. Pupils are equal, rounded, and reactant to light and accommodations. No visual changes were reported and deny the usage of glasses. No difficulties hearing and no complaint of tinnitus and vertigo. The tympanic membrane is intact upon assessment. The patient can differentiate between different smells. No septum deviation was noted nor runny nose. The tongue is pink and symmetrical with no signs of ulcerations. No swollen nodes or missing teeth. the patient states his gums “sometimes bleed when brushing teeth.”
Neck: no signs of lumps, goiter, or swollen glands. Pain with movement.
Breast and Axillae: no discharge or pain was recorded. No lumps noted.
Respiratory: lung sounds are clear bilateral. No complaint of shortness of breath.
Cardiovascular: S1 and S2 present, no S3 or S4. The patient denies chest pain, palpitations, or tightness.
Peripheral vascular: denies numbness, tingling, and swelling. Upon assessment, extremities are warm to touch.
Gastrointestinal: patient denies a decrease in appetite, heartburn, nausea, and vomiting. Patient bowel movements are regular, with occasional diarrhea. The patient states no black stools.
Musculoskeletal: the patient denies pain in joints, swelling, or deformities. The patient reports neck pain since the automobile accident. He denies weakness, gait, or coordination problems.
Neurologic: He denies seizures, stroke, or tremors. The patient reports no mood swings or memory disorders.
Urinary: denies urgency, frequency, or incontinence. No report of discoloration or blood in the urine.
Male genital system: There are no lumps or lesions present. He denies pain and discharge. He reports no problem with ejaculation nor erection.
Nutritional Assessment
24-hour diet collection:
Breakfast: fasting
Snack: Ham and cheese sandwich with water
Lunch: steak, rice, and beans bowl with lettuce, tomatoes, and corn.
Snack: a cup of milk and some crackers
Dinner: HE has meat and whole wheat rice with baked potato, banana, and cucumber.
Patient N.T BMI is 29 for his weight and height. He is overweight, but he is an athletic fit. In addition, the patient has changed his diet to a more nutritious one high in fruits and fibers.
Nutritional Assessment
24-hour diet collection:
Breakfast: fasting
Snack: Ham and cheese sandwich with water
Lunch: steak, rice, and beans bowl with lettuce, tomatoes, and corn.
Snack: a cup of milk and some crackers
Dinner: meat and whole wheat rice with baked potato, banana, and cucumber.
Patient N.T BMI is 29 for his weight and height he is overweight, but he is muscular fit. The patient has changed his diet to a more nutritious one high in fruits and fibers.
Risk Factors
Patient N.T has a family history of renal and cardiac failure. As well as diabetes mellitus type I. The patient has physical hazards at work due to location and work description. The patient stays away from the grandmother whenever she is smoking.
Health Promotion
The patient is to follow up with PCP regarding neck pain. The patient is adjusting the number of carbohydrates in his diet to keep sugar levels under control. The patient tries to stay active and not keep a sedentary lifestyle. The patient drinks 7 cups of water and denies the use of carbonated drinks. The patient denies the usage of tobacco, alcohol, and recreational/ illicit drugs. He wears the seatbelt regularly while inside a car. The patient does not exceed the exposure to the sun, and when he does, he wears sunblock and long sleeve clothing. The patient states he makes sure the smoke detectors at home are working.
