NUR2092 WRITE-UP—HEALTH HISTORY
Classroom Assignment Week Two
Date _04/15/2022 Examiner ___
- Biographic Data Name ____Aisha Brown
Phone_____7737578441
Address_____1750 w farwell Chicago Illinois
Birthdate ____12/10/1988
Birthplace __Rockford Age _34 Gender _Female Marital Status __single
Occupation __Student Race/ethnic origin ___Africa American
Employer ___Walgreen
- Source and Reliability __From patient
- Reason for Seeking Care: Constipation
- Present Health or History of Present Illness : None
Past Health
Describe general health ____Fair
Childhood illnesses ____Gastroenteritis
Accidents or injuries (include age) __N/A
Serious or chronic illnesses (include age) ____N/A
Hospitalizations (what for? location?) __N/A
Operations (name procedure, age) __N/A
Obstetric history: Gravida ____N/A Term __N/a Preterm _____N/A (# Pregnancies)
(# Term pregnancies) (# Preterm pregnancies)
Ab/incomplete ___N/A. Children living _____N/A (# Abortions or miscarriages) _____N/A
Course of pregnancy___N/A (Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery or cesarean section, complications, baby’s condition)
Immunizations__Up to date
Last examination date: Physical _______12/12/2021
Dental ___12/05/2021 Vision ____11/28/2021 Allergies _____N/A
Reaction ___N/A
Current medications ________Miralax
- Family History—Specify Which Relative(s)
Heart disease__________________N/A High blood pressure____YES Father
Stroke_________________________N/A Diabetes__________________N/A
Blood disorders__________________N/A Breast or ovarian cancer______N/A
Cancer (other)___________________N/A Sickle cell___________________N/A
Arthritis_________________________N/A
Allergies________________________N/A Asthma ___________________N/A
Obesity_________________________N/A Alcoholism or drug addiction __N/A
Mental illness ____________________N/A Suicide ___________________N/A
Seizure disorder __________________N/A Kidney disease _________________N/A
Tuberculosis _____N/A
Review of Systems (Circle/highlight both past health problems that have been resolved and current problems, including date of onset.)
General Overall Health State: Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweats: NONE
Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion:NONE
Hair: Recent loss, change in texture : NONE
Nails: Change in shape, color, or brittleness: NONE
Health Promotion: Amount of sun exposure, method of self-care for skin and hair
N/A
Head: Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo:NONE
Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts :NONE
Health Promotion Eyes: Wears glasses or contacts, last vision check or glaucoma test, how coping with loss of vision, if any N/A
Ears: Earaches, infections, discharge and its characteristics, tinnitus, or vertigo N/A
Health Promotion Ears: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning ears
Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell:NONE
Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste:NONE
Health Promotion/Mouth & Throat: Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkup
Neck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter:NONE
Breast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts Axilla: Tenderness, lump or swelling, rash:NONE
Health Promotion Breast: Performs breast self-examination, including frequency and method used, last mammogram and results:NONE
Respiratory System: History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure Health Promotion Respiratory: Last chest x-ray examination: NONE
Cardiovascular System: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia
Health Promotion Cardiovascular: Date of last ECG or other heart tests and results: NONE
Peripheral Vascular System: Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers Health Promotion Peripheral Vascular: If work involves long-term sitting or standing, avoid crossing legs at the knees; wear support hose: NONE
Gastrointestinal System: Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula)
Health Promotion Gastrointestinal: Use of antacids or laxatives
Urinary System: Frequency, urgency, nocturia (the number of times awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low back
Health Promotion Urinary: Measures to avoid or treat urinary tract infections, use of Kegel exercises:NONE
Male Genital System: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia :NONE
Health Promotion Male Genital: Perform testicular self-examination? How frequently?NONE
Female Genital System: Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding. NONE
Health Promotion Female Genital: Last gynecologic checkup, last Pap test and results
Last pap test 02/10/2021
Result: Negative
Sexual Health: Presently in a relationship involving intercourse? Are aspects of sex satisfactory to you and partner, any dyspareunia (for female), any changes in erection or ejaculation (for male), use of contraceptive, is contraceptive method satisfactory? Use of condoms, how frequently? Aware of any contact with partner who has sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, syphilis) None
Musculoskeletal System: History of arthritis or gout. In the joints: pain, stiff-ness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait prob-lems or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease.
None
Health Promotion Musculoskeletal: How much walking per day? What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? Any mobility aids used?
Neurologic System: History of seizure disorder, stroke, fainting, blackouts. In motor function: weakness, tic or tremor, paralysis, coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation). In mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations.
Hematologic System: Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.
Endocrine System: History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat or cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy.
Functional Assessment (Including Activities of Daily Living)
Self-Esteem, Self-Concept: Education (last grade completed, other significant training) __College
Financial status (income adequate for lifestyle and/or health concerns) __Income adequate for lifestyle
Value-belief system (religious practices and perception of personal strengths) _____Muslim
Self-care behaviors _______Eating Healthy and Look good
Activity and Exercise: Daily profile, usual pattern of a typical day ___go to gym every sunday
Independent or needs assistance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, climbing stairs ___________________None
Leisure activities ______________Spend with friends
Exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring Treadmill every sunday
Sleep and Rest: Sleep patterns, daytime naps, any sleep aids used ___________________
Nutrition and Elimination: Record 24-hour diet recall. ___No diet restriction
Is this menu pattern typical of most days? __No
Who buys food? _______________________Patient buy food
Who prepares food? ____________________Patient prepare the food
Finances adequate for food? ______________yes
Who is present at mealtimes? _________________patient
Interpersonal Relationships and Resources: Describe own role in family ______very well
How getting along with family, friends, co-workers, classmates _____________very well
Get support with a problem from? _____________________________________Boyfriend
How much daily time spent alone? ____________________________________NONE
Is this pleasurable or isolating? ___________________________________________Pleasureable
Coping and Stress Management: Describe stresses in life now ___Combing school with work
Change(s) in past year _______________________________None
Methods used to relieve stress _____________________Watch movies
Are these methods helpful? _______________________yes
Personal Habits:
Daily intake caffeine (coffee, tea, colas) ___None
Smoke cigarettes? __________No Number packs per day _____N/A
Daily use for how many years ________NO Age started __NO
Ever tried to quit? _________________N/A How did it go? ____N/A
Drink alcohol? _______________N/A Date of last alcohol use _____ N/A
Amount of alcohol that episode ___________________________________N/A
Out of last 30 days, on how many days had alcohol? ____________________NO
Ever told had a drinking problem? ____NO
Any use of street drugs? ___NO Marijuana? ________NO
Cocaine? _____________NO Crack cocaine? _______NO
Amphetamines? _______NO Heroin? _________NO
Prescription painkillers? _________NO Barbiturates? _______NO
LSD? ________________NO
Ever been in treatment for drugs or alcohol? __NO
Environment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors) ___Apartment
Safety of area _______Good
Adequate heat and utilities ___yes
Access to transportation _____Car
Involvement in community services __No
Hazards at workplace or home _____N/A
Use of seatbelts _Yes
Travel to or residence in other countries ___N/A
Military service in other countries __________N/A
Self-care behaviors _____________________________________________________________________ Intimate Partner Violence: How are things at home? Do you feel safe? __YES
Ever been emotionally or physically abused by your partner or someone important to you___-NO
Ever been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner? ___NO
Partner ever force you into having sex? ____NO
Are you afraid of your partner or ex-partner? __NO
Occupational Health:
Please describe your job. ___Work at Walgreen as Pharmacy tech
Work with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)? __no
Any equipment at work designed to reduce your exposure? N/A
Any work programs designed to monitor your exposure? _N/A
Any health problems that you think are related to your job? ____N/A
What do you like or dislike about your job? ____Help to improve other lives’ but its stressful somethings
Perception of Own Health:
How do you define health? ______State of complete physical, mental and social well-being and not merely the absence of disease or infirmity
View of own health now _________Healthly
What are your concerns? _____None
What do you expect will happen to your health in future? __Expect to remain healthy in future
Your health goals ________Eat healthy, exercise more and maintain a healthy life
Your expectations of nurses, physicians _____friendly atmosphere, listen to all my complain, speck to me calmly and follow up with my concerned
