NUR2092 WRITE-UP—HEALTH HISTORY Classroom Assignment Week Two

NUR2092 WRITE-UP—HEALTH HISTORY Classroom Assignment Week Two

Date ___4/16/22____________ Examiner _ __________

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1. Biographic Data Name: ___ _____________________________________ Phone_________________ Address__ Il_________________ Birthdate ________________________________ Birthplace ______ ________ Age __37________ Gender _____Male_____ Marital Status _Married _____________ Occupation __Independent Contractor________ Race/ethnic origin __ _____________________ Employer __ __________________

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2. Source and Reliability: From Patient

 

3. Reason for Seeking Care: Annual medical check-up

 

4. Present Health or History of Present Illness: None

 

 

Past Health

Describe general health __Good____________________________________________________ Childhood illnesses ____None____________________________________________________________ Accidents or injuries (include age) ___None________________________________________________ Serious or chronic illnesses (include age) _None______________________________________________ Hospitalizations (what for? location?) ___None_______________________________________________ Operations (name procedure, age) _____None_______________________________________________ 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 immunization____________________________________________

Last examination date: Physical ________________

Dental ____9/_14/2021___________ Vision __11/17/2021________ Allergies __None____________ Reaction ___None_________________________

 

 

Current medications ___None___________________________________________ _

6. Family History—Specify Which Relative(s)

Heart disease: _None_______________________ High blood pressure: _Father_____________

Stroke: _Father______________________ Diabetes: ___None ____________________________

Blood disorders: _______None _______________ Breast or ovarian cancer: ____None________

Cancer (other): ____None______________________ Sickle cell: __None __________________

Arthritis: ____None_____________________ Allergies: ____None___________________________ Asthma: None __________________

____ Obesity: ___None____________________________ Alcoholism or drug addiction _None _____________

Mental illness _None____________________ Suicide ___None____________________________

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: None

Ears: Earaches, infections, discharge and its characteristics, tinnitus, or vertigo: None

Health Promotion Ears: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning ears: None

 

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: None

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: N/A

Health Promotion Breast: Performs breast self-examination, including frequency and method used, last mammogram and results: N/A

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: None

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: None

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. N/A

Health Promotion Female Genital: Last gynecologic checkup, last Pap test and results; N/A

Sexual Health: Presently in a relationship involving intercourse? Yes. Are aspects of sex satisfactory to you and partner? Yes. any dyspareunia (for female), any changes in erection or ejaculation (for male) None. use of contraceptive, is contraceptive method satisfactory? N/A. Use of condoms, how frequently? None. 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 problems 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? 2 miles What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? None. Any mobility aids used? None

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. None

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. None

Functional Assessment (Including Activities of Daily Living)

Self-Esteem, Self-Concept: Education (last grade completed, other significant training) __University____________

Financial status (income adequate for lifestyle and/or health concerns) __________

Value-belief system (religious practices and perception of personal strengths) ___________

Self-care behaviors _Eating a good balance diet and very active_____________________

Activity and Exercise: Daily profile, usual pattern of a typical day __Exercise once in a week by walking 2 miles ______________________

Independent or needs assistance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, climbing stairs ___None______________________________

Leisure activities ____Spend time with family____________________________________

Exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring: Walking

Sleep and Rest: Sleep patterns, daytime naps, any sleep aids used __None_________________

Nutrition and Elimination: Record 24-hour diet recall. __No diet restriction _____________________________________ _____________________________________________________________________________________

Is this menu pattern typical of most days? ___________________________________________________

Who buys food? __The Patient buy his food__________________________

Who prepares food? ___The patient’s wife prepares the food and the patient assist in the kitchen______________________

Finances adequate for food? ___Yes_______________________________

Who is present at mealtimes? __The patient ________________________________

Interpersonal Relationships and Resources: Describe own role in family __Father_______________________

How getting along with family, friends, co-workers, classmates _Patient get along very well with friends and family_____________________

Get support with a problem from? ____wife __________________________________________

How much daily time spent alone? ____None spent most time with family_______________________ Is this pleasurable or isolating? Pleasurable____________________________________________

Coping and Stress Management: Describe stresses in life now __Combining work and family together ________________________________ _____________________________________________________________________________________ Change(s) in past year ______None________________________________________

Methods used to relieve stress __relaxing and movie_____________________

Are these methods helpful? _Yes__________________________

Personal Habits:

Daily intake caffeine (coffee, tea, colas) __None____________________________________

Smoke cigarettes? ___None________________ Number packs per day ___None___________

Daily use for how many years ___N/A___________ Age started __N/A_________

Ever tried to quit? __N/A__________________ How did it go? ___N/A___________________

Drink alcohol? _No__________________ 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? ____________________________________

Ever told had a drinking problem? __No__________________________________________________ Any use of street drugs? __None______Marijuana? _None________________________________

Cocaine? ____None______________________________ Crack cocaine? __N/A__________________ Amphetamines? __N/A______________ Heroin? ____N/A______________

Prescription painkillers? ___N/A____________ Barbiturates? ___N/A____________________________ LSD? ____N/A_________________________________

Ever been in treatment for drugs or alcohol? __N/A______________________________________________

Environment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors) _City, Live with family ____________________________________________________________________________________

Safety of area ___Good________________________________________________________________ Adequate heat and utilities _____Good___________________________________________________

Access to transportation ____Yes________________________________________________________

Involvement in community services ___No_________________________________________________ Hazards at workplace or home ___None___________________________________________________ Use of seatbelts _______Yes_____________________________________________________________

Travel to or residence in other countries ___No_____________________________________________ Military service in other countries ___No_______________ Self-care behaviors _______________ Intimate Partner Violence: None How are things at home? Good 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. ___Independent Contractor___________________________

Work with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)? _________________No__________________________________________________________________

Any equipment at work designed to reduce your exposure? No

Any work programs designed to monitor your exposure? ____No_____________________________

Any health problems that you think are related to your job? __No___________________________

What do you like or dislike about your job? ___I like the fact that is flexible for me _________________

Perception of Own Health:

How do you define health? _My health has been good so far_________________________

View of own health now __No major illness which I’m happy about. Everything looks perfect______________________________________________________________

What are your concerns? __None ______________________________________________________________

What do you expect will happen to your health in future? ___considering the fact that I don’t have any underlying illness, I expect to be healthy in future like I am right now. ____________________

Your health goals __continue to maintain my weight, eat more of healthy food to keep healthier____________________________________________________________________

Your expectations of nurses, physicians _I expect the nurse and physicians to responds to my concerns/ needs when needed and also continue to treat all the patient with respect and love like they have been doing __________________________________________________

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