NUR2092 WRITE-UP—HEALTH HISTORY Classroom Assignment Week Two
Date ___4/16/22____________ Examiner _ __________
1. Biographic Knowledge Title: ___ _____________________________________ Phone_________________ Address__ Il_________________ Birthdate ________________________________ Birthplace ______ ________ Age __37________ Gender _____Male_____ Marital Standing _Married _____________ Occupation __Independent Contractor________ Race/ethnic origin __ _____________________ Employer __ __________________
2. Supply and Reliability: From Affected person
three. Cause for Searching for Care: Annual medical check-up
four. Current Well being or Historical past of Current Sickness: None
Previous Well being
Describe basic well being __Good____________________________________________________ Childhood diseases ____None____________________________________________________________ Accidents or accidents (embrace age) ___None________________________________________________ Critical or persistent diseases (embrace age) _None______________________________________________ Hospitalizations (what for? location?) ___None_______________________________________________ Operations (identify process, age) _____None_______________________________________________ Obstetric historical past: Gravida __N/A__________ Time period ___N/A_________ Preterm ___N/A_________ (# Pregnancies) (# Time period pregnancies) (# Preterm pregnancies) Ab/incomplete _N/A____________________ Kids residing _____N/A________________ (# Abortions or miscarriages) _N/A____
Course of pregnancy____N/A____________________________________________________________ (Date supply, size of being pregnant, size of labor, child’s weight and intercourse, vaginal supply or cesarean part, issues, child’s situation) Immunizations: _Up to this point immunization____________________________________________
Final examination date: Bodily ________________
Dental ____9/_14/2021___________ Imaginative and prescient __11/17/2021________ Allergic reactions __None____________ Response ___None_________________________
Present drugs ___None___________________________________________ _
6. Household Historical past—Specify Which Relative(s)
Coronary heart illness: _None_______________________ Hypertension: _Father_____________
Stroke: _Father______________________ Diabetes: ___None ____________________________
Blood problems: _______None _______________ Breast or ovarian most cancers: ____None________
Most cancers (different): ____None______________________ Sickle cell: __None __________________
Arthritis: ____None_____________________ Allergic reactions: ____None___________________________ Bronchial asthma: None __________________
____ Weight problems: ___None____________________________ Alcoholism or drug habit _None _____________
Psychological sickness _None____________________ Suicide ___None____________________________
Seizure dysfunction __N/A______________________ Kidney illness __N/A________________________ Tuberculosis _N/A____
Overview of Programs (Circle/spotlight each previous well being issues which were resolved and present issues, together with date of onset.)
Basic General Well being State: Current weight (achieve or loss, time period, by weight loss program or different elements), fatigue, weak point or malaise, fever, chills, sweats or night time sweats. None
Pores and skin: Historical past of pores and skin illness (eczema, psoriasis, hives), pigment or colour change, change in mole, extreme dryness or moisture, pruritus, extreme bruising, rash or lesion: None
Hair: Latest loss, change in texture: None
Nails: Change in form, colour, or brittleness: None
Well being Promotion: Quantity of solar publicity, methodology of self-care for pores and skin and hair: N/A
Head: Any unusually frequent or extreme headache, any head damage, dizziness (syncope), or vertigo: None
Eyes: Issue with imaginative and prescient (decreased acuity, blurring, blind spots), eye ache, diplopia (double imaginative and prescient), redness or swelling, watering or discharge, glaucoma or cataracts: None
Well being Promotion Eyes: Wears glasses or contacts, final imaginative and prescient test or glaucoma take a look at, how dealing with lack of imaginative and prescient, if any: None
Ears: Earaches, infections, discharge and its traits, tinnitus, or vertigo: None
Well being Promotion Ears: Listening to loss, listening to support use, how loss impacts day by day life, any publicity to environmental noise, methodology of cleansing ears: None
Nostril and Sinuses: Discharge and its traits, any unusually frequent or extreme colds, sinus ache, nasal obstruction, nosebleeds, allergic reactions or hay fever, or change in sense of odor: None
Mouth and Throat: Mouth ache, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered style: None
Well being Promotion/Mouth & Throat: Sample of day by day dental care, use of prostheses (dentures, bridge), and final dental checkup: None
Neck: Ache, limitation of movement, lumps or swelling, enlarged or tender nodes, goiter: None
Breast: Ache, lump, nipple discharge, rash, historical past of breast illness, any surgical procedure on breasts Axilla: Tenderness, lump or swelling, rash: N/A
Well being Promotion Breast: Performs breast self-examination, together with frequency and methodology used, final mammogram and outcomes: N/A
Respiratory System: Historical past of lung illness (bronchial asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest ache with respiratory, wheezing or noisy respiratory, shortness of breath, how a lot exercise produces shortness of breath, cough, sputum (colour, quantity), hemoptysis, toxin or air pollution publicity Well being Promotion Respiratory: Final chest x-ray examination: None
Cardiovascular System: Precordial or retrosternal ache, palpitation, cyanosis, dyspnea on exertion (specify quantity of exertion it takes to provide dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, historical past of coronary heart murmur, hypertension, coronary artery illness, anemia
Well being Promotion Cardiovascular: Date of final ECG or different coronary heart exams and outcomes: None
Peripheral Vascular System: Coldness, numbness and tingling, swelling of legs (time of day, exercise), discoloration in fingers or toes (bluish crimson, pallor, mottling, related to place, particularly round toes and ankles), varicose veins or issues, intermittent claudication, thrombophlebitis, ulcers Well being Promotion Peripheral Vascular: If work entails long-term sitting or standing, keep away from crossing legs on the knees; put on help hose. None
Gastrointestinal System: Urge for food, meals intolerance, dysphagia, heartburn, indigestion, ache (related to consuming), different belly ache, pyrosis (esophageal and abdomen burning sensation with bitter eructation), nausea and vomiting (character), vomiting blood, historical past of belly illness (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel motion, any latest change, stool traits, constipation or diarrhea, black stools, rectal bleeding, rectal circumstances, hemorrhoids, fistula)
Well being Promotion Gastrointestinal: Use of antacids or laxatives: None
Urinary System: Frequency, urgency, nocturia (the variety of instances awakens at night time to urinate, latest change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine colour (cloudy or presence of hematuria), incontinence, historical past of urinary illness (kidney illness, kidney stones, urinary tract infections, prostate); ache in flank, groin, suprapubic area, or low again: None
Well being Promotion Urinary: Measures to keep away from or deal with urinary tract infections, use of Kegel workouts: None
Male Genital System: Penis or testicular ache, sores or lesions, penile discharge, lumps, hernia: None
Well being Promotion Male Genital: Carry out testicular self-examination? How incessantly? None
Feminine Genital System: Menstrual historical past (age at menarche, final menstrual interval, cycle and length, any amenorrhea or menorrhagia, premenstrual ache or dysmenorrhea, intermenstrual recognizing), vaginal itching, discharge and its traits, age at menopause, menopausal indicators or signs, postmenopausal bleeding. N/A
Well being Promotion Feminine Genital: Final gynecologic checkup, final Pap take a look at and outcomes; N/A
Sexual Well being: Presently in a relationship involving intercourse? Sure. Are points of intercourse passable to you and accomplice? Sure. any dyspareunia (for feminine), any adjustments in erection or ejaculation (for male) None. use of contraceptive, is contraceptive methodology passable? N/A. Use of condoms, how incessantly? None. Conscious of any contact with accomplice who has sexually transmitted an infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, syphilis)? None
Musculoskeletal System: Historical past of arthritis or gout. Within the joints: ache, stiff-ness, swelling (location, migratory nature), deformity, limitation of movement, noise with joint movement. Within the muscle groups: any ache, cramps, weak point, gait issues or issues with coordinated actions. Within the again: any ache (location and radiation to extremities), stiffness, limitation of movement, or historical past of again ache or disk illness. None
Well being Promotion Musculoskeletal: How a lot strolling per day? 2 miles What’s the impact of restricted vary of movement on day by day actions, corresponding to on grooming, feeding, toileting, dressing? None. Any mobility aids used? None
Neurologic System: Historical past of seizure dysfunction, stroke, fainting, blackouts. In motor perform: weak point, tic or tremor, paralysis, coordination issues. In sensory perform: numbness and tingling (paresthesia). In cognitive perform: reminiscence dysfunction (latest or distant, disorientation). In psychological standing: any nervousness, temper change, despair, or any historical past of psychological well being dysfunction or hallucinations. None
Hematologic System: Bleeding tendency of pores and skin or mucous membranes, extreme bruising, lymph node swelling, publicity to poisonous brokers or radiation, blood transfusion and reactions. Endocrine System: Historical past of diabetes or diabetic signs (polyuria, polydipsia, polyphagia), historical past of thyroid illness, intolerance to warmth or chilly, change in pores and skin pigmentation or texture, extreme sweating, relationship between urge for food and weight, irregular hair distribution, nervousness, tremors, want for hormone remedy. None
Practical Assessment (Together with Actions of Each day Residing)
Self-Esteem, Self-Idea: Schooling (final grade accomplished, different important coaching) __University____________
Monetary standing (earnings ample for way of life and/or well being considerations) __________
Worth-belief system (spiritual practices and notion of non-public strengths) ___________
Self-care behaviors _Eating a very good stability weight loss program and really active_____________________
Exercise and Train: Each day profile, ordinary sample of a typical day __Exercise as soon as in every week by strolling 2 miles ______________________
Impartial or wants help with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair switch, strolling, standing, climbing stairs ___None______________________________
Leisure actions ____Spend time with family____________________________________
Train sample (kind, quantity per day or week, methodology of warm-up session, methodology of monitoring: Strolling
Sleep and Relaxation: Sleep patterns, daytime naps, any sleep aids used __None_________________
Vitamin and Elimination: Document 24-hour weight loss program recall. __No weight loss program restriction _____________________________________ _____________________________________________________________________________________
Is that this menu sample typical of most days? ___________________________________________________
Who buys meals? __The Affected person purchase his food__________________________
Who prepares meals? ___The affected person’s spouse prepares the meals and the affected person help within the kitchen______________________
Funds ample for meals? ___Yes_______________________________
Who’s current at mealtimes? __The affected person ________________________________
Interpersonal Relationships and Assets: Describe personal function in household __Father_______________________
How getting together with household, buddies, co-workers, classmates _Patient get alongside very nicely with buddies and family_____________________
Get help with an issue from? ____wife __________________________________________
How a lot day by day time spent alone? ____None spent most time with family_______________________ Is that this pleasurable or isolating? Pleasurable____________________________________________
Coping and Stress Administration: Describe stresses in life now __Combining work and household collectively ________________________________ _____________________________________________________________________________________ Change(s) in previous 12 months ______None________________________________________
Strategies used to alleviate stress __relaxing and movie_____________________
Are these strategies useful? _Yes__________________________
Private Habits:
Each day consumption caffeine (espresso, tea, colas) __None____________________________________
Smoke cigarettes? ___None________________ Quantity packs per day ___None___________
Each day use for what number of years ___N/A___________ Age began __N/A_________
Ever tried to stop? __N/A__________________ How did it go? ___N/A___________________
Drink alcohol? _No__________________ Date of final alcohol use __N/A_____
Quantity of alcohol that episode ______N/A____________________________________________________
Out of final 30 days, on what number of days had alcohol? ____________________________________
Ever advised had a ingesting downside? __No__________________________________________________ Any use of avenue medication? __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 therapy for medication or alcohol? __N/A______________________________________________
Atmosphere and Hazards: Housing and neighborhood (kind of construction, reside alone, know neighbors) _City, Reside with household ____________________________________________________________________________________
Security of space ___Good________________________________________________________________ Sufficient warmth and utilities _____Good___________________________________________________
Entry to transportation ____Yes________________________________________________________
Involvement in neighborhood providers ___No_________________________________________________ Hazards at office or residence ___None___________________________________________________ Use of seatbelts _______Yes_____________________________________________________________
Journey to or residence in different nations ___No_____________________________________________ Army service in different nations ___No_______________ Self-care behaviors _______________ Intimate Accomplice Violence: None How are issues at residence? Good Do you’re feeling secure?___Yes____________
Ever been emotionally or bodily abused by your accomplice or somebody necessary to you: __No_-
Ever been hit, slapped, kicked, pushed, or shoved or in any other case bodily harm by your accomplice or ex-partner? No______________________________________________________________________________ Accomplice ever drive you into having intercourse? _No__________________________________________ Are you afraid of your accomplice or ex-partner? ____No____________________________
Occupational Well being:
Please describe your job. ___Independent Contractor___________________________
Work with any well being hazards (e.g., asbestos, inhalants, chemical compounds, repetitive movement)? _________________No__________________________________________________________________
Any gear at work designed to cut back your publicity? No
Any work applications designed to watch your publicity? ____No_____________________________
Any well being issues that you simply suppose are associated to your job? __No___________________________
What do you want or dislike about your job? ___I like the truth that is versatile for me _________________
Notion of Personal Well being:
How do you outline well being? _My well being has been good so far_________________________
View of personal well being now __No main sickness which I’m pleased about. Every little thing seems to be perfect______________________________________________________________
What are your considerations? __None ______________________________________________________________
What do you anticipate will occur to your well being in future? ___considering the truth that I don’t have any underlying sickness, I anticipate to be wholesome in future like I’m proper now. ____________________
Your well being targets __continue to keep up my weight, eat extra of wholesome meals to maintain healthier____________________________________________________________________
Your expectations of nurses, physicians _I anticipate the nurse and physicians to responds to my considerations/ wants when wanted and in addition proceed to deal with all of the affected person with respect and love like they’ve been doing __________________________________________________
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NUR2092 WRITE-UP—HISTORY OF HEALTH Classroom Assignment Week Two Date ___4/16/22____________ Examiner _ __________
1. Biographic Knowledge Title: ___ _____________________________________ Cellphone _________________ Address__ Il_________________ Birthdate ________________________________ Birthplace ______ ________ Age __37________ Gender _____Male_____ Marital Standing _ Married _____________ Occupation __Independent Contractor________ Race/ethnic origin __ _____________________ Employer __ __________________
2. Supply and Reliability: From Affected person
three. Cause for Searching for Care: Annual medical check-up
four. Current Well being or Historical past of Current Sickness: None
Previous Well being
Describe basic well being __Good____________________________________________________ Childhood diseases ____None____________________________________________________________ Accidents or accidents (embrace age) ___None________________________________________________ Critical or persistent diseases (embrace age) _ None______________________________________________ Hospitalizations (what for? location?) ___None_______________________________________________ Operations (identify process, age) _____None_______________________________________________ Obstetric historical past: Gravida __N/A__________ Time period ___N/A_________ Preterm ___N/A_________ (# Pregnancies) (# Time period pregnancies) (# Preterm pregnancies) Ab/incomplete _N/A____________________ Kids residing _____N/A________________ (# Abortions or miscarriages) _N/A____
Course of being pregnant
____N/A____________________________________________________________ ( Date supply, size of being pregnant, size of labor, child’s weight and intercourse, vaginal
