Stratford NSG330 Partner Health History Paper

Partner Health History Paper

Health History

Biographic Data

Name: A.S

Address: 1122 Stratford Place, Woodbridge, VA 22193

Date of Birth: 03/27/1963

Birthplace: Arlington, VA

Marital Status: Married

Occupation: Retired

Race/ Ethnic Origin: White/ Caucasian

A.S is 57 year old female, she has been retired for 8 years.

Source:

Patient, seems reliable with husband, also seems reliable.

Reason for Seeking Care:

Increased Right sided UE and LE weakness, slurred speech.

History of Health/ Present Illness:

Previous CVA in September 2019 (MRI w/ and w/o contrast: acute lacunar strokes in anterior basal ganglia and internal capsule on left and in the left central pons; nonspecific small area of enhancement in right basal ganglia possibly from subacute strokes; old encephalomalcic changes in both frontal lobes. Bilateral carotid u/s: negative- no atherosclerosis plaque in either bifurcation region. On d/c she was started on baby aspirin 2x per day; since was discontinued by patient), residual weakness, requires use of cane for ambulation, chronic uncontrolled hypertension (currently untreated), hyperlipidemia; untreated due to medication noncompliance (last fasting lipid panel in 01/2019; total cholesterol at 178,triglycerides at 127, HDL at 42, LDL at 111), DMtype 2: diet controlled. Last HbA1c in 01/2019 at 5.7. Seizure disorder, previous EEG done at initial presentation of seizure event demonstrated right sided frontotemporal slowing and spiked discharges. Patient was found by husband approximately 0400, patient was laying on the couch, unable to stand, respond appropriately to questioning or speak coherently. Husband stated the room was in disarray, possibly from a fall. He also reports possible urinary incontinence with wet spot on the couch by the patient. Patient presented to ED with right upper and lower extremity weakness, slurred, speech and disorientation. Patient was unable to recall most of the night’s events, but states she fell on her buttocks. Patient also stated that she felt like she was speaking weirdly although she knew what she wanted to say. Husband reports that the right sided extremity weakness is considerably worse in regards to LE strength and ambulation. Patient admits to significant cocaine use and medication noncompliance since June 2019. Patient denies head trauma, headache, change in vision, n/v, dizziness, SOB, chest pain, or palpitations.

 

Past Health

General Health: Overweight

Childhood Illnesses: Seizures

Chronic Illnesses: Seizure disorder, hyperlipidemia, hypertension, DM type 2

Accidents or Injuries: MVA as child (age 13) with concussion/ front lobe injury

Hospitalizations: September 2019 following CVA

Operations: 2 cesarean sections age 26 and 30 years old

Obstetric History: Gravida: 4 Term 4 Preterm 0 Ab/incomplete: 0 Living: 4

Course of pregnancies: 4 to term, 1982 male, 1984 male, 1986 cesarean female, 1991 cesarean female.

Immunizations: All up to date, No flu shot.

Last Exam Date: Physical 2019, Dental: 2015, Vision 2019

Allergies: none known

Current medications:

Non-compliant with current prescribed medication regimen. Prescribed baby aspirin 81mg every day, KCl 20 mEq PO every day, Zocor (simvastatin) PO 40mg every day hour of sleep. HCTZ 25mg PO every day, Lotrel (amlodipine/ benzapril) PO 10/20mg every day, no herbal medications or OTCs.

Family History:

Mother: alive and well

Father: Deceased in mid 60’s of cancer, type is unknown

Otherwise family hx is unknown, no relationship with rest of family

Social History:

Patient is currently living with her husband, daughters and grandchildren. They have 4 children, 2 daughters live with her and husband. She maintains a relationship with her mother and 2 daughters but doesnot maintain relations with 2 sons and rest of family. Recently, she lost her medical insurance (Medicaid) and she cannot afford to see her PCP or follow up with physical therapy for CVA rehab. She is now in the process of applying for disability, she is retired but states that the financial help is not enough. Due to lack of finances she has been taking her prescribed medications since June of 2019. She has completed high school with her diploma and did receive an associate’s degree in IT. ADL’s are limited. Her husband prepares food and helps her bath but she maintains ability to perform essential tasks such as brushing teeth and feeding herself. She does report smoking ciggerettes, half a pack a day, and denies alcohol use. She does have a significant cocaine habit, smoking approximately once per week for the past 2 years, although her husband states that this has been going on for a lot longer.

 

ROS:

Constitutional: Some fatigue onset today, overweight (after turning 50), right sided extremity weakness following CVA in September 2019. Denies any malaise, fever chills, sweats, or night sweats. Denies depression, anxiety, mood changes.

Skin: Denies history of skin disease, color is appropriate for race/ ethnicity. Denies any moles, excessive dryness, pruritus, excessive bruising, rash or lesion.

Hair: Denies any recent changes.

Nails: Denies any change is color, shape, or brittleness. No sun screen use, does spend time outside in the summer months.

Head: Weekly headaches, onset many years ago chronic. Denies head injury, vertigo

Eyes: Denies any difficulty with vision, eye pain, or cataracts. No glasses or contacts. Last vision check was January 2019 with glaucoma check.

Ears: Denies pain, discharge

Nose/ Sinuses: Denies discharge, pain.

Mouth and Throat: Denies any pain, soreness, bleeding. Does exhibit slurred speech, onset in September 2019 following CVA. Brushes her teeth 2x per day. Root canal and past cavities.

Neck: Denies any pain or swelling

Breast: Does not perform self-examinations. Denies tenderness, swelling, lumps, or surgery.

Respiratory: No history of lung disease. Current smoker, half a pack a day. No SOB or increased work of breathing.

Cardiovascular: No murmur. Chronic hypertension, hyperlipidemia (MRI, Bilateral carotid U/S in September 2019) See history for findings.

Peripheral Vascular: Varicose veins in bilateral LE’s, sedentary lifestyle, prolonged sitting at home. Denies numbness/ tingling, discoloration.

Gastrointestinal: Decreased appetite. Denies abdominal pain, diarrhea, n/v, constipation

Urinary: History suggests loss of continence, pt denies incontinence or change in frequency, color or odor.

Female Genitalia: Menopause onset age 55, denies hot flashes, sweating, lower abdominal pain, post-menopausal bleeding.

Sexual Health: Reported lack of sex drive, libido. Denies pain with intercourse or STI’s.

Musculoskeletal: Right hand stiffness, weakness is right side LE and UE. Unsteady gait, use of cane for ambulation. Patient does not prepare meals for herself and requires help with bathing from husband. Limited walking per day.

Neurologic: Seizure disorder(since childhood), CVA (Sept 2019), altered mental status following CVA, recent blackout (see above) Slurred speech. Denies numbness/ tingling.

Hematologic: Denies transfusions/ reactions, excessive bruising or bleeding.

Endocrine: DM type 2 onset in 40’s. Denies heat/cold intolerance, thyroid disease, or hormonal therapy. (Menopausal onset age 55)

Functional Assessment:

Self-Esteem/ Self Concept: Graduated high school with diploma, obtained Associate’s degree in IT

Financial Status:Insufficient, no insurance, applying for disability. Noncompliant with medication regime due to financial hardship.

Value/ Belief System:Catholic

Self-Care Behaviors:Spends quality time with husband, daughters and grandchildren

Activity/ Exercise ADL’s: None, sedentary lifestyle, requires the assistance of her husband for preparing meals and bathing. Uses cane for ambulation due to Right sided weakness. She can brush her teeth and eat unassisted.

Sleep and Rest: Average 7hrs of sleep per night with a nap during the day.

Nutrition and Elimination: Reports sweet tooth for chocolate and snacks throughout the day. Typical breakfast is eggs, pancakes, bacon, cereal and orange juice. Lunch: hamburgers, fries (fast food). Dinner: Fast food, pork chops, potatoes, chicken, soda, chips. Recently she is not as hungry as usual and reports skipping dinner last night and lunch yesterday. Husband typically prepares and buys food. They are on government assistance (SNAP).

Interpersonal Relationships and Resources:  Helps care for grandchildren, feels close to mother, husband and daughters as well. Estranged relationship with both sons and rest of family. States she is not often alone in the home.

Coping and Stress Management: Current stressors in life are financial hardship, health, substance abuse, weight. Use of cigarettes and cocaine to relieve stress. Reports that these help her feel better most of the time.

Personal Habits: Caffeine intake: 2 cups of coffee daily and 3 sodas daily, current smoke, half a pack a day, for the past 30 years, started in late 20’s, no alcohol use. No alcohol use in the past 30 days. Never has had a drinking problem. Illicit drug use: Cocaine only. Has attended rehab in the past but did not finish program.

Environment and Hazards: Lives in 2 story stand-alone house in subdivision, friendly neighbors. Area is safe. Adequate heat and cooling. Access to transportation: husband drives in family car/ No involvement in community services. Hazards at home: stairs, 5 steps to enter home and stairs in home to reach 2nd level, approximately 20 stairs. Uses seatbelts. No travel or residence to other countries. No military service in other countries.

Intimate Partner Violence:Feels safe at home, no abuse from anyone important or by partner. Never been hit, slapped, kicked, pushed, shoved or otherwise physically hurt by partner or important person in life. Partner has never forced her into having sex. Never has she felt afraid of her partner or ex-partner.

Occupational Health: Retired, does not apply.

Perception of Own Health: Defines health as important to her. View herself as unhealthy now. Concerns reported are weight, overall health, stroke, seizures, addiction to cocaine and cigarettes. She reports that she expects to have another stroke in her future. Health Goals: start taking prescribed medications, stop drug use and smoking cigarettes, lose weight. Expectations of nurses, physicians: to guide her through process and help her feel better. Referral to resources.

 

If you are in a clinic, jail, or in a situation where you do the history and physical exams as a registered nurse, you will need to know how to interview a patient for a health history and doing a genogram.

Attached is a document with the criteria for writing your complete health history paper.  Also attached is a sample paper turned in by a Stratford U. student who received an A on her paper.

You will be interviewing another student who is acting and pretending to have a particular type of illness and the student will fabricate a story of his/her illness so you can do a thorough health history on the student.