1 Running Head: HEALTH HISTORY

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Health History Assignment

2 Running Head: HEALTH HISTORY CLIENT PROFILE Name: DOB: 01/27/1973 Sex: Female a!e: "a#!asian $arital Stat#s: $arrie% eligion: Does not i%enti&y 'ith any religion O!!#(ation: F#ll)time st#%ent/$other *rimary +ang#age: ,nglish Allergies: No -no'n So#r!e o& .n&ormation: *atient

HEALTH STATUS eason &or see-ing !are: tire% all the time no matter ho' m#!h slee(/ &re0#ent hea%a!hes 1)2/'-)slight #(on 'a-ening 3#t 3#il% #( to #n3eara3le an% at that (oint are #nres(onsi4e to ot! i3#(ro&in/ s'elling o& lo'er legs)le&t 'orse than right x 1 month/ 5o4er emotional6)!ries or angers easily 5!an7t e4en g#ess ho' long it7s 3een li-e this 3e!a#se it7s 3een so long6 *er!e(tion o& illness: (atient thin-s (ossi3le (erimeno(a#se is !a#se o& emotional state/ !on!erne% that s'elling o& lo'er legs might 3e heart iss#e/ thin-s hea%a!hes are %#e to (re4io#sly %iagnose% 8a3o#t 2 yr ago9 !er4i!al arthritis ,&&e!t o& illness on AD+s: not a!!om(lishing all o& %aily tas-s) ex: home'or-/ !oo-ing %inner/ ho#se'or-: Slee(ing o%% ho#rs/ staying #( all night to &inish tas-s not gotten to %#ring the %ay: Health rating 8s!ale o& 1)10 'ith 10 ; ex!ellent9: "#rrent: < Fi4e years ago: 9 Fi4e years &rom no': 10

3 Running Head: HEALTH HISTORY S(e!ial health ha3its: gets *A* 1/yr/ sees %entist 2/yr/ has all !hil%hoo% imm#ni=ations/ #( to %ate tetan#s/ &l# shot 1/yr (er s!hool re0#irements/ has not exer!ise% in 2 mo>ha% (re4io#sly exer!ise% reg#larly S#3stan!e #se: 5so!ial6 al!ohol #se)%rin-s al!ohol a3o#t e4ery !o#(le o& months an% !ons#mes 1)2 %rin-s/ #s#ally 4o%-a: Sto((e% smo-ing 01/22/2010 a&ter 19yrs o& 1(-/%ay: Denies #se o& illegal %r#gs/(res!ri(tion nar!oti!s: $e%i!al/S#rgi!al History: ")se!tion 809/20/19979/ %enies any illness asi%e &rom 5normal6 !hil%hoo% illness) !hi!-en(ox 819?09/ 3reast a#gmentation 8200<9 $e%i!ations: i3#(ro&en or as(irin &or hea%a!hes>#s#ally ta-es 2 ta3lets 3#t has ta-en #( to &o#r &or @extreme7 hea%a!hes/ ti=ani%ine &or sho#l%er/ne!-/hea% (ain asso!iate% 'ith arthritis>2 ta3lets at 3e%time 'hen ne!essary Family History: $other)age <1/ ali4e an% 'ell/ !er4i!al !an!er at age 23/ #n%er'ent ra%i!al hystere!tomy Aran%(arents>maternal gran%&ather %ie% at <</ m#lti(le stro-esB maternal gran%mother age ?? has arthritis an% high B*/ other'ise healthyB (aternal gran%&ather %ie% at 72 o& heart &ail#reB (aternal gran%mother %ie% at <7/ a!t#al !a#se o& %eath #n-no'n 3#t (re4io#sly ha% stro-e an% heart atta!-: So!ial History: marrie% 11yrs/ not ha((ily>(lan on %i4or!ing as soon as gra%#ates &rom !ollege/ !#rrently li4ing as roommates/ 1 !hil%) 13 yrs o& age N#tritional History: (ast 1 yr not !oo-ing/ eating resta#rant an% &ast &oo% &or maCority o& meals/ has gaine% 10 l3 in 3 months/6 extremely #nha((y a3o#t that6 Aeneral o3ser4ations: (atient a((ears 'ell groome%/ alert/ !oo(erati4e/ 'ith !lear !on!ise s(ee!h/ has #(right (ost#re/ a((ro(riate &a!ial ex(ressions an% 3eha4ior: BODY SYSTEMS Skin, Hair, Nail ! Denies s-in in&e!tion/ rashes/ lesions/ or it!hing: Denies !hanges in si=e or !olor o& moles: Dses s#ns!reen in s#mmer months only an% only 'hen at the (ool/ not on a %aily 3asis: Ehin-s that amo#nt o& %aily hair loss in sho'er is a3normally high an% also &eels as i& hair is thinning: Nails are 53#m(y6 an% they s(lit sin!e 'henF H"a#, N"$k, an# L%&'(a)i$! Arthritis in !er4i!al s(ine %iagnose% 200? a&&e!ts O$ 'hen &lare%/ s(ora%i! 3o#ts o& &re0#ent hea%a!hes 8sometimes as little as 3/month an% other times as o&ten as 2/'ee-9 %#e to arthritis an% tension/ most !ommon lo!ation is 3ase o& s-#ll #( to to( o& 3a!- o& hea%/ relie4e% 'ith i3#(ro&en or as(irin/ sometimes as m#!h as ?00 mg i3#(ro&en or 972 mg o& as(irin: Denies %isease% thyroi% glan%:

4 Running Head: HEALTH HISTORY E%" ! Near)sighte%/ 'ears !orre!ti4e !onta!ts/ 3#t 4ision is 3l#rry myo(iaF0/ has not ha% eye exam in 3 years: History o& in&e!tion an% !orneal la!erations %#e to im(ro(er !onta!t lens #se/ no in!i%en!es in the (ast < years: Ear, N* ", M*+)(, an# T(r*a)! +istens to lo#% m#si! in !ar/ %enies !hanges in hearing/ (ain/ in&e!tion/ %rainage: Dses !otton s'a3s insi%e ear !anal: Denies any lesions or no%#les on ears: Denies any (ain/ ten%erness/ o& nose an% sin#ses: Breathes 5!lear6 ex!e(t 'hen has a !ol%: Denies !ol% sores/ (ain o& the mo#th or throat/ in&lame% g#ms or lesions: Gisits %entist e4ery < months/ 3r#shes 2x %aily ex!e(t 'hen 5exha#ste%6 an% &losses a&ter (o(!orn only: One !hi((e% tooth on 3ottom/ has ha% sin!e < th gra%e/ 5is not a (ro3lem6: ,(istaxis

R" 'ira)*r%! History o& smo-ing to3a!!o/ 19 (a!- years: States !essation on 01/22/2010: Denies 'hee=ing/ shortness o& 3reath/ !o#gh ex!e(t 'hen has a !ol%/ or (ain: Denies allergies: Denies mo#th 3reathing/ or (ro3lems 'ith 3reathing 'hile lying %o'n: Denies any 'eight loss or light)hea%e%ness: A%mits lo' energy le4el: Car#i*,a $+lar! S'ollen lo'er legs &rom -nee %o'n/ le&t more so than right/ &or 1 month: 5O!!asional6 %i==iness #(on stan%ing 5may3e a !o#(le times a 'ee-/ not s#re/ %on7t -ee( tra!-6: Feet 5al'ays6 !ol%/ sometimes (#r(le &or 5years6>al'ays tho#ght it 'as (oor !ir!#lation %#e to smo-ing:: e!ently/ 5a3o#t a 'ee- ago6 a'a-ene% &rom slee( 3y !al& (ain: *al(itations 'hen ner4o#s: Denies !hest (ain/ m#rm#r/ high !holesterol/ or high B*: $aternal gran%mother has high B*/ 3oth (aternal gran%(arents ha% heart %isease: Br"a ) an# A-illa"! A#gmentation 8200<9 %enies any !om(li!ations o& s#rgery/ ten%erness r/t menstr#al !y!le/ %enies &amily history o& 3reast !an!er/ %enies any l#m(s/ lesions/ ni((le %is!harge/ or !hanges in s-in o& ni((le or areola: Denies sel& examination: P"ri'("ral .a $+lar! A%mits s'elling o& lo'er legs x1 month) le&t leg 'orse than right>al'ays at en% o& %ay s#3si%es 'ith ele4ation/ 5tingly n#m3)li-e6 &eeling in &eet x 1 month>al'ays at en% o& %ay s#3si%es 'ith ele4ation/ han%s s'ell 'ith exer!ise x 1yr/ legs 53alloone% #( really 3ig6 'hile Cogging 2 %i&&erent times in (ast < months/ han%s an% &eet 5al'ays6 !ol% 5&or as long as !an remem3er6/ toes t#rn 5(#r(lish6 o!!asionally>'hen really !ol%/6 3een li-e that &or years6/ ex(erien!ing leg !ram(s x 1 month/ a%mits not a%e0#ately hy%rating>se4eral %ays in s#!!ession 'itho#t %rin-ing 'ater/ %enies ro#tine exer!ise: Denies any lesions/ #l!ers on legs or arms/ %enies any s'ollen glan%s: /a )r*in)" )inal! A%mits !hanges in a((etite an% 'eight (ast < months relates this to smo-ing !essation an% stress/ s#&&ers &rom !onsti(ation at least 1x month sometimes a!!om(anie% 3y se4ere a3%ominal (ain)) %enies treatment/ a%mits to in!rease in gas relates to (oor !hanges in %iet/ %enies na#sea/ 4omiting/ an% in%igestion/ a%mits to high %aily inta-e o& !a&&eine>20 o= !o&&ee/ 20)32 o= !ola/ 20)32 o= green or 3la!- tea: Urinar%! Goi%s almost 1x e4ery ho#r/ states this is normal (attern %#e to !onstant inta-e o& &l#i%/ a%mits to 1 DE.s o4er (ast 2 years/ &eels it7s getting har%er to 5hol% it6 a%mits to 5a han%&#l o& small a!!i%ents6 o4er (ast yr/ gets #( at night to #rinate/ al'ays has>%rin-s &l#i%s #( #ntil goes to 3e%/ a%mits to !olor

5 Running Head: HEALTH HISTORY !hanges o& light an% %ar- yello' relate% to 'ater inta-e/ %enies any in&e!tion/ (ain/ or o%ori&ero#s or !lo#%y #rine: R"'r*#+$)i,"! Onset o& menses at 12 yrs o& age/ menstr#al !y!le is 5#n(re%i!ta3le/ ne4er -no's 'hen it7s !oming6>(ast 2 yrs/ has a menstr#al (erio% e4ery 1?)22 %ays/ 3lee%ing lasts 1)2 %ays 'ith 5resi%#e6 lasting another 2)3 %ays/ has 1 healthy !hil% %eli4ere% 3y !esarean/ (remat#re la3or 2x 3e&ore %eli4ering >to!olyti!s #se%/ sex#ally a!ti4e in monogamo#s relationshi( / %enies !ontra!e(tion #se/ %enies history o& SEDs/ %enies any rashes/ #l!ers/ sores/ 'arts/ l#m(s/ it!hing/ or %is!harge in 4aginal or re!tal areas/ $other ha% !er4i!al !an!er: M+ $+l* k"l")al! A%e0#ate mo3ility/ arthritis in !er4i!al s(ine %iagnose% 200? !a#ses 3#rning sensation/ s'elling/ sti&&ness an% limite% O$ treate% 'ith ti=ani%ine/ i3#(ro&en or as(irin/ stret!hes an% strengthening exer!ises/ 1 &ra!t#re le&t h#mer#s at 12 yrs o& age/ %enies m#s!le 'ea-ness/ m#s!le or Coint (ain other than that asso!iate% 'ith arthritis: N"+r*l*0i$! Denies ina3ility to !arry o#t AD+s ex!e(t those %#e to (oor time management/ %enies &ainting/ sei=#res/ !on4#lsions/ !hanges in hearing/ smell or taste: A%mits to !hanges in 4ision/ (res!ri(tion -ee(s getting stronger/ %enies any (ain/ re!reational %r#g #se/ or memory loss: A%mits tingling an% n#m3ness in &eet (ast 1 month al'ays o!!#rs in e4ening:

S+12"$)i," Pr*1l"& Li ) 1: Nee%s e%#!ation on time management:

2: Nee%s e%#!ation on ho' ro#tine exer!ise !an ai% in mo3ility an% (ain management/ heart health/ an% relie4ing stress: 3: Nee%s e%#!ation on ho' a healthy %iet !ontri3#tes to nail an% hair health: 1: Nee%s e%#!ation on a heart healthy %iet: 2: Sho#l% !onsi%er !o#nseling &or stress %#e to marital iss#es: <: Nee%s e%#!ation on the a%4erse e&&e!ts o& o4er #sing OE" me%i!ations: 7: Nee%s an eye examination: ?: Nee%s e%#!ation on the a%4erse e&&e!ts o& lo#% m#si!: 9: Nee%s e%#!ation on the (ro(er #s o& !otton s'a3s: 10: Nee%s e%#!ation on the im(ortan!e o& reg#lar &lossing an% mo#th health: 11: Nee%s me%i!al e4al#ation o& !ar%io4as!#lar system %#e to (eri(heral e%ema an% (oor !ir!#lation in &eet/toes: 12: Nee%s e%#!ation (ertaining to the im(ortan!e o& monthly 3reast sel&)examination:

6 Running Head: HEALTH HISTORY 13: Nee%s e%#!ation on (ro(er hy%ration an% the a%4erse e&&e!ts o& %ehy%ration as (ertains to s'elling an% m#s!le !ram(s: 11: Nee%s me%i!al e4al#ation o& !ir!#latory system: 12: Nee%s e%#!ation on the a%4erse e&&e!ts o& high !a&&eine inta-e: