CHA AHP

Running Head: HEALTH HISTORY 1

Health History

NURS 7180: Advanced Physical Assessment

James Doe

Dr. Shirley Comer

October 24, 2014

HEALTH HISTORY 2

Health History

Identification: AR, F, 58 years old

Informant: Patient, reliable source

Chief Complaint: “I run out of pain medication. I have trouble walking and taking a breath. My

pain is flaring up.”

History of Present Illness (HPI): Experiencing chronic muscular low back pain radiating to her

lower extremities (back of her thighs) for 3 years. Currently pain is 7 of 10- normally is 3 of 10.

Oftentimes, when pain gets uncontrolled, she suffers generalized pain from her back to her

upper and lower extremities, shoulders and head. Pain is constant and can be aggravated with

long hours of standing from work. However, it is controlled with her medication treatment

including Gabapentin 100mg three times a day, Ativan 0.5mg HS, Tramadol 50mg four times a

day, PRN and use of back brace support.

Past Medical History (PMI):

 Current medications: Gabapentin 100mg three times a day, Ativan 0.5mg every hour of

sleep, Tramadol 50mg four times a day, PRN, Hydrochlorothiazide 25mg daily, Amino acid

1 tablet twice a day, Omega-3 1 capsule three times a day, Glucosamine 1 capsule three

times a day, Vitamin C 1000mg daily, and Vitamin B12 1 capsule daily. All prescribed

medications are taken as ordered.

 Allergies: No known drug and food allergies.

 Surgeries: Tubal ligation, 1986, right upper chest excision of cyst, 1988, occipital head

laceration requiring 3 stitches from physical assault, 2006.

HEALTH HISTORY 3

 Hospitalizations/Non-surgical: Childbirth times 4 per vaginal delivery in the year 1981,

1982, 1985 and 1986.

 Trauma: MVA with no fractures, 2008 and physical assault resulting to occipital head

laceration requiring 3 stitches, 2008.

 Current and past medical problems:

Disease Dx date Resolved or continuing

Status

Hypertension 2006 C Well controlled with meds HTCZ

Hyperlipidemia 2006 C Diet controlled Chol 220 in 10/10

Scoliosis 2005 C Pain controlled by meds

Lung Nodule 2005 C Stable – yearly CXR

Pneumonia 2013 R Outpatient

 Infectious diseases: (received BCG vaccine as a child in the Philippines), requiring a yearly

chest X-ray). Last CXR 6/14. Had Varicella at age 8, no other infectious diseases.

Vaccine Received

Influenza 10-13

Pnemoncoccal none

Tetnus, diphtheria, pertussis (Td/Tdap)

2008

Varicella None had disease age 8

Human Papillomavirus (HPV) none

Zoster none

Measles, Mumps, Rubella (MMR)

Immunized as a child

Meningocaccal none

Hepatitis A none

Hepatitis B 2 doses in 2007

 Health maintenance:

HEALTH HISTORY 4

o Brisk walking for 20-30 minutes three times per week

o Compliance with healthy regime and prescribed medications

o Follows a heart healthy diet: low sodium and low cholesterol which include

healthy grains, fruits, vegetables, lean proteins, low intake of saturated and trans

fats and avoiding processed foods

o 24 diet recall- Breakfast: Toast with butter, coffee. Lunch: Tuna salad

sandwich, apple, starbucks’ cold coffee. Dinner: Chicken breast, Salad,

Chocolate cake. Snacks: pretzels, soft drink

o Routinely goes to the clinic for follow up visits (latest visit was 07/2014)

o Recent screening tests: Mammogram (2014), colonoscopy (2011), Pap smear

(2013); unremarkable tests results

o Yearly receives flu vaccine (Sept 2013)

o Received Tetanus vaccine in 2008 after the physical assault experienced

 Family History

Maternal Grandparents- Unknown- mother was adopted

Paternal Grandparents- Grandmother died age 88 of CVA- had CHF and DMII.

Grandfather died age 52 of MI-no previous history.

Parents- Mother age 72 with HTN. Father age 77 with Parkinson’s disease and HTN.

Aunt/Uncles- Aunt age 80 with HTN, CHF

Cousins- 2 Female ages 44, 50 in good health. 1 male age 55 with DMII and HTN.

Siblings- sister 54 in good health

Nieces/Nephews- Niece age 22 in good health

Children- Male age 25 in good health. Female age 20 with Down’s syndrome.

Grandchildren- Male age 3 mons- in good health.

HEALTH HISTORY 5

 Psychosocial History: Married with 4 children and living in the same household with strong

familial support to each other. Currently works as a registered nurse in Cook county clinic

with HMO insurance. Denies use of alcohol and illicit drug. Reports cigarette smoking in the

past for 2 pack-years, quit 1980. Drinks 1 cup of coffee in the morning before going to

work, brisk walking done 20-30minutes three times per week, follows a healthy regimen

however, reports sleeping 5-6 hours per night. Enjoys watching TV on her off days and goes

to church every Sunday. Mostly, at home when off at work; reports financial problems as

one of her life stressors.

 Review of Systems

General: Denies pain, fever, chills, malaise and fatigability. Reports no changes in

appetite and unexpected weight loss.

Skin, Hair and Nails : Reports no rashes, pruritus, bruising, dryness, lesions, skin cancer,

change in hair or nail texture, nail ridges or pigmentation. Uses hair dye to color graying

hair. Uses sunscreen regularly during the summer.

Head: Experiences intermittent headache when back pain is uncontrolled. Located in

bilateral temples, 4 of 10. Relieved with rest and Tylenol. Denies trauma, dizziness or

fainting.

Eyes: Last eye exam 9/11. Wears prescription glasses for reading and corrective lenses

on social occasions. Denies vision or visual field changes, diplopia blurring, burning,

discharge dry eye, cataracts, or glaucoma.

Ears: Last hearing exam, 5 years ago. Denies hearing problems or infections. Denis

tinnitus, pain, discharge, vertigo, or frequent ear infections.

HEALTH HISTORY 6

Nose: No history of epistaxis, obstruction, polyps, or sinus infections. Denies any

problems with smell and taste.

Mouth/Throat: Last dental exam 6/10. Complaints of bad breath and frequently uses

mouth wash or chew gum. Denies pain or difficulty in swallowing. Denies bleeding

gums, painful teeth, mouth ulcers/lesions, hoarseness, frequent pharyngitis, changes in

taste, snoring or sleep apnea. States brushes teeth twice daily and flosses daily.

Respiratory: Denies dyspnea, pain, sneezing, wheezing, sputum or hemoptysis. Denies

history of pneumonia, bronchitis, asthma. Reports history of smoking in the past for

2pack-years, quit 1980. Last chest X-ray, June 2010, revealed stable lung nodule

unchanged from previous 2009 CXR, requires a yearly chest X-ray for follow up r/t

receiving the BCG vaccine as a child in the Philippines .

Cardiovascular: No complaints of chest pain, orthopnea, dyspnea with or without

exertion, peripheral edema, murmurs, or palpitations. Reports controlled hypertension

while being compliant with prescribed medication. Stress test done 2009 was normal.

Peripheral vascular: Denies claudication and edema. No history of deep vein thrombosis

or non-healing wounds. Denies varicosities, cold or pale extremities.

Gastrointestinal: Denies changes in appetite and unexpected weight loss. Reports

eating a high fiber diet to maintain regularity in the bowel movement; Last BM 1-1-12.

Last colonoscopy, 2011, revealed colon polyps; removed and biopsy done with negative

malignancy, next colonoscopy will be done a year after. Denies dysphagia, heartburn,

nausea and vomiting, indigestion, abdominal pain, diarrhea or constipation. Denies

jaundice, or food intolerances.

HEALTH HISTORY 7

Gynecological: Reports age of onset of menses at 14 years old with monthly periods of

3-4 days with moderate flow. Gravida 4/Para 4/Abortions 0, living children aged 30, 28,

26 and 24. Reports childbirth per vaginal delivery without complications. Reports

menopause at age 55 years. Denies STDs. Performs breast self-exam once a month. Last

mammogram, 2010 and Pap smear, 2011, revealed negative result. States has on is

monogamous with husband and is satisfied with sex life.

Genitourinary: Denies frequency, hesitancy/changes in stream, dysuria, hematuria,

polyuria, polydipsia, nocturia, incontinence. Voids clear yellow urine several times/day.

Endocrine: Denies polyuria, polydipsia, polyphagia, glycosuria and temperature

intolerance, glycosuria, changes in hair, skin texture, fatigue, weight changes, or goiter.

Musculoskeletal: Complaints of chronic muscular back pain for 3 years. Pain rating is 5

of 10. Reports scoliosis since 2005. No limitations in the range of motion. No history of

gout and arthritis.

Hematologic: No C/o cold intolerance, fatigue, bleeding tendencies, bruising,

lymphadenopathy, or history of anemia.

Neurological: No history of head injury, seizure, syncope, weakness. Denies episode of

TIA or stroke. No loss of sensation, coordination or balance.

Psychiatric: Denies changes in mood, memory, sleep patterns, emotional disturbances.

No history of substance abuse.

Summary of Significant Findings:

Constant chronic muscular back pain for 3 years treated with Gabapentin 100mg three

times a day, Ativan 0.5mg every hour of sleep, Tramadol 50mg four times a day, PRN and use of

HEALTH HISTORY 8

back brace support as well as reported scoliosis since 2005; controlled hypertension and

hyperlipidemia with medication, diet and activity; ex-smoker for 2pack-years; intermittent

headache experienced during uncontrolled back pain; colon polyps however, removed during

colonoscopy screening. Familial history of hypertension, Down’s syndrome, diabetes mellitus,

CVA and CHF.