Health History

Youngstown State University Department of Nursing NURSG 2643 HEALTH HISTORY DOCUMENTATION FORM Date of Interview: 11-6-2016 I. Biographical Data:

Interviewer: Caliope Gialousis _________________

Client's Initials: VLR Age: 60 Birth date: 3-9-1956 Sex: F Marital Status: M Usual

Birthplace: Pittsburgh, Pennsylvania Race: White

Ethnic Origin: Irish

Occupation: Special Needs Mentor

Present Occupation: Special Needs Mentor II. Source of Data: Interviewee III. Reason for Seeking Care (Chief Complaint): “For a Physical Exam” IV. Present Health (History of Present Illness): “I am fairly healthy” V. Past Health (Past History): A. Childhood Illness / Immunizations: No history of rubella, pertussis, rheumatic fever, scarlet fever, or polio myelitis. History of measles-1962, age 6. Mumps-1964, age 8. Chicken pox-1963, age 7. History of strep throat through early adulthood, led to tonsillectomy in 1974. Immunizations: Tetanus-1972, age 16. Polio-1962, age 6. B. Accidents or Injuries: Car accident, age 18. No hospitalization or after effects. C. Serious of Chronic Illnesses: No asthma, hypertension, HIV infection. No hepatitis, sickle cell, anemia, or seizure disorder. History of depression, diagnosed at age 24. Takes Doxipin 2x daily to treat. “Very manageable.” Gestational Diabetes, age 39 during second pregnancy. Heart attack, age 60. No prior heart disease. Melanoma skin cancer, age 40.

D. Hospitalizations and Operations: Tonsillectomy-1974 age 18. Pittsburgh Children’s Hospital, doctor unknown. Recovery went well. Rotator cuff surgery- March 2014 age 58. Southwoods Surgical Center, Dr. Pantilakis. Slow recovery with rehab. Bicep Reconstruction- September 2014 age 58. Southwoods Surgical Center, Dr. Pantilakis. Continued recovery with rehab. Heart Attack- July 27-30, 2016. Dr. Varghesse, continued recovery going well.

E.

Obstetric History: First child- September 1, 1982, age 25. Dr. Caldwell, St. Vincent Hospital

in Erie, PA. 2 day stay, recovery went well. Second child- August 24, 1995, age 39. Dr. Leonelli, Northside Hospital. 2 day stay, recovery went well.

F. Adult Immunizations: Flu vaccine-yearly. Tetanus-2014, age 59. TB skin test- 2006, age 60. Shingles-2016, age 60. G. Last Examination Date: The most recent physical and electrocardiogram was October 26, 2016. Last dental exam was 1 year ago. Does not recall last chest x-ray. Last vision exam was 2015 for new glasses. Never had a hearing exam. H. Allergies / Reactions: Medication- allergic to Sulfa (hives). No food or environmental allergies.

How would you describe your health? “Overall I am healthy but I need to improve my diet and get on a better exercise plan. I am trying to improve my cardiac health as well.”

VI. Medications

Dose

Dosage Times

1.

Lisinopril Ticagrelor Atorvastin Metoprolol Succinate Vitamin D Hydroxyzine Asprin Dapsone Doxepin

10mg 90 mg 80 mg 25 mg 50,000 units 25 mg 81 mg 25 mg 100 mg

1x daily 1 tablet 2x daily 1x nightly 1x nightly 1x weekly 3x daily 1x daily 1-am, 2-pm 1-am, 3-pm

Lorazepam

.5 mg

3x daily

2.

3. 4.

5. 6. 7. 8. 9. 10.

VII. Family History (include family tree): Strong family history of heart disease and alcoholism.

VIII. Social History, Culture, Religion, Education: Raised in the United States and has a strong Irish Culture. Strong belief in God and practices Greek Orthodoxy. Education status is two years of classes taken at Penn State and no degree received. IX. Review of Systems: A. General Overall Health State: Present weight is 190 pounds with no abnormal increase or decrease. States weight is “too much.” No fatigue, weakness or malaise, fever or chills, and or night sweats.

B. Skin: No history of skin disease (eczema, psoriasis, hives). Age related dark spots. No change in moles. No excessive dryness or moisture, pruritus, rash or lesions. Bruising more than normal due to blood thinner. Sun exposer is minimal. Uses sunscreen during direct exposure.

C. Hair: No hair loss or texture change.

D. Nails: No change in shape, color, or brittleness.

E. Head: No unusual frequent or severe headaches. No head injury or dizziness, or vertigo. F. Eyes: Difficulty with vision for many years, decreased acuity (nearsighted and farsighted), treated with bifocals. Last vision exam in 2015 for new glasses. No blurring or blind spots. No eye pain, diplopia, redness, swelling, watering or discharge, glaucoma, or cataracts.

G. Ears: No earaches, discharge, tinnitus, or vertigo. No hearing loss or hearing aid. No exposure to environmental noises. Cleans ear with Q-Tip daily. Never had a hearing exam.

H. Nose and Sinuses: No discharge, frequent cold, sinus pain, nasal obstruction, nose bleeds, allergies, or change in smell.

I. Mouth and Throat: No mouth pain, frequent sore throat, bleeding gums, toothache, lesions or mouth or tongue, dysphagia, hoarseness, or change in voice or taste. Occasional cold sores, treated with OTC medication. Brushes and flosses 2-3 times daily. Last dental exam in 2015. Entire upper row of teeth removed in 2013 and replaced by implants. Tonsillectomy in 1974 at Pittsburgh Children’s Hospital. Doctor unknown. Recovery went well.

J. Neck: No pain, limitation of motion, lumps, swelling, enlarged or tender nodes, or goiter.

K. Breast: No lumps, pain swelling, nipple discharge, rash, or breast disease. Performs monthly self-breast exams and yearly mammograms.

L. Axilla: No tenderness, lumps, swelling, or rash.

M. Respiratory System: No history of lung disease (asthma, emphysema, bronchitis, pneumonia, TB). No chest pain with breathing. Gets short of breath after exercise but is decreasing as heart strength increases. No cough, sputum. No hemoptysis. No toxin or pollution exposure.

N. Cardiovascular System: No pericardial or retrosternal pain. No palpitation, cyanosis, dyspnea on exertion, orthopnea, nocturia, edema. No history of heart murmur, hypertension, or anemia. History of coronary artery disease. Acute ST elevation Myocardial Infarction involving the LAD.

O. Peripheral Vascular System: No coldness, numbness, tingling, swelling of legs, discoloration in hands or feet, varicose veins, or complications. No intermittent claudication, thrombophlebitis, or ulcers. Usually standing for 4 hours at work, tends to rest more since heart attack. No long term sitting, no habit of crossing legs at knees. No use of support hose.

P. Gastrointestinal System: Appetite (well, regular). No food intolerance, dysphagia, or pain. History of heart burn and indigestion with acidic foods. No abdominal pain, pyrosis, nausea, vomiting, vomiting blood. No history of abdominal disease (ulcers, liver, gallbladder, jaundice, appendicitis, colitis). No flatulence. No change in frequency of bowel movement (1-2 times per day). Stool characteristics soft, formed, brown, with no diarrhea. Occasional constipation, fixed by drinking more water. No bloody or black stool. Q. Urinary System: Frequency (every 2-3 hours). No urgency, nocturia, dysuria, polyuria, oliguria, straining, or narrowed stream. Urine is clear, pale yellow, with no cloudiness or blood. No incontinence or history of urinary disease. No kidney disease or kidney stones. History of occasional urinary tract infection. No pain in flank, groin, suprapubic region, or low back. R. Male/Female Genital System: No vaginal pain, sores or lesions, discharge, lumps, hernia. Gets Pap Test every 2-3 years.

S. Sexual Health: Currently sexually active, satisfied. Monogamous with husband of 25 years. No changes. No contact with partner who has a sexually transmitted infection. T. Musculoskeletal System: No history of arthritis. No joint pain, stiffness, swelling, deformities, lack of motion, or noise with joint motion. No muscle pain, cramps, weakness, or gait problems. Has problems with coordination activities. No other pain to other locations or radiation to other extremities. No stiffness, limitation of motion, or history of back pain or disc disease. Distance walked per day is around 12,000 steps. No limited range of motion with daily activities. History of poor range of motion in left shoulder due to torn rotator cuff. Fixed with outpatient surgery in 2014. By Dr.Pantilakis at Southwoods Surgery Center. Range of motion was restored. U. Neurologic System: No history of seizure disorder, stroke, fainting, or blackouts. No weakness, paralysis, or coordination problems in motor function. History of essential tremors that began in 2010 and were diagnosed in 2012. Progressively worsening with age. In sensory function there is no numbness and tingling. In cognitive function there is no diagnosed memory disorder but states “short term memory is worsening with age.” No disorientation. No mood change. History of depression since 1983 and is now managed with medication. History of situational nervousness and anxiety. Diagnosed in 2013 and treated with medication.

V. Hematologic System: No bleeding of skin or mucous membrane, lymph node swelling, exposure to toxic radiations. No blood transfusions. Moderate bruising related to medications.

W. Endocrine System: History of Gestational Diabetes during second pregnancy. No history of thyroid disease, intolerance to heat and cold, change in skin texture, or excessive sweating. Age related dark spots. No relationship between appetite and weight, abnormal hair distribution. Has situational nervousness and essential tremors. No need for hormone therapy

X. Functional Assessment: A. Self-Esteem/Self-Concept: Feels financially adequate for lifestyle but health expenses are overwhelming. Strong belief in God and attends church regularly. Has strong family values. Personal strengths are intelligence, good at job, mother, and caring for others. B. Activity/Exercise: Works 20 hours/week. Comes home and spends time with family followed by daily chores. Tolerates activity in moderation. No regular exercise pattern. Leisure activities are spending time with family, and reading. C. Sleep/Rest: Sleeps 7-8 hours a night without sleep aids. Occasionally naps during the day. Length of nap depends on daily activity. D. Nutrition/Elimination: 24 hour recall on attached sheet. This is a typical daily menu with some variation. Typically does not eat breakfast but eats lunch, dinner, and some snacks. Cooks dinner regularly for herself and family and eats with them in the evening. Eats lunch and snacks at work with co-workers. Will either pack a lunch or get something on-the-go during break time. Husband buys groceries and finances are adequate for food. No allergies or intolerances. Has one cup of coffee per day and 2-3 diet cola beverages. E. Interpersonal Relationships/Resources: Roles are mother, mentor, caregiver, friend. Good relationship with family, friends, and co-workers. Support system consists of family, mainly mother and daughter. Personal problems are fixed with help of daughter. Problems at work are easy to solve with supervisor help. Medical problems are treated by various doctors. Has alone time when daughter is out, but enjoys company of dogs.

F. Coping and Stress Management: Stresses in life have been more than normal over the last 2 years due to marital problems. Has been trying to decrease stress since heart attack. Has trouble relieving stress but is working on ways to do so.

G. Personal Habits: Does not smoke. Previously smoke for 25 years, quit immediately after heart attack. No drug use (marijuana, cocaine, amphetamines, or barbituates). History of alcoholism. Sober for 25 years. H. Environment/Hazards: Have safe home in safe area. Lives with daughter and knows neighbors. Has adequate heat and utilities, transportation. No involvement in community services. No hazards at home, work. No geographical or occupational exposures. No traveling to other countries. Does use seatbelts. Takes measures to stay safe. I. Occupational Health: “I am a mentor at a bakery that provides supportive employment for people with special needs.” Reported getting much enjoyment helping special needs people. No chemical or environmental hazards at work. Likes flexibility and support of co-workers. No dislikes.