NURS 3308 Health History Template 1 Health History Date: 5/25/2020 I. Student: Sydney Short A. Biographic Data: Birthplace: Longview Lab Day/Time: Thursday 9am-12pm Patient’s initials: B.S. Age: 24 Where raised: Longview Language(s) spoken: English Primary language: English Race(s): Caucasian (Non-Hispanic) Ethnic origin: Irish & Native American Marital Status: Single Gender: Male Occupation: Student Religion: Agnostic Subcultures patient is a member of: N/A B. Source and Reliability: Patient himself, who seems reliable. II. Reason for seeking care (Chief Complaint): Patient noticed a lump in lower right testicle and complained of slight pain and sensitivity. III. History of Present Illness (or Present Health): Symptom analysis of the 8 variables 1. Body location: Right genital region 2. Quality: Sensitivity and throbbing pain in genital region 3. Quantity (scale 0-10): 3/10 pain 4. TimingOnset: The first symptom appeared four days ago, pain began last night. Duration: Intermittent pain. Frequency: Lump has been consistent & has not grown; pain onset every 3-4 hours. 5. Setting: The patient noticed the symptom upon waking, 4 days ago. 6. FactorsAggravating: Wearing tight clothing, hot water, physical activity. Alleviating: Cool compress, avoiding physical activity. 7. Associated factors: N/A 8. Patient’s perception of the symptoms: Patient states that physical activity has decreased significantly since the onset of these symptoms. IV. Past health: 1. Childhood illnesses with age(s): Influenza at age 7, but otherwise healthy childhood. 2. Accidents and injuries: Dog attack at age 11; Athletic facial injury at age 13; Sprained ankle at age 19. 3. Serious or chronic illnesses: N/A NURS 3308 Health History Template 2 4. Hospitalizations: N/A 5. Surgeries: Tonsillectomy, Adenoidectomy, Wisdom Teeth Removal 6. Obstetric history: N/A 7. Immunizations-Childhood vaccines: All vaccines have been up to date. Hepatitis B: Tetanus: Flu: Pneumonia vaccine: TB Skin Test: 2/14/20 Other: 8. Last Exam DatePhysical: 2/14/2020 Dental: 1/23/2020 Vision: 7/18/2020 Hearing: N/A 9. Allergies and reaction to eachThe patient reports no allergies or allergic reaction. 10. Current Medications (Add or delete rows as needed) Medication (Include OTC, herbal or vitamins) Fish Oil Why taking Dose Route (how taken) Promote heart health 2,000mg Oral Frequency (how often taken) Twice a week How long taken Classification 7 years OTC Vitamin V. Family History: 1. Heart Disease: Maternal Grandfather High blood pressure: Maternal Grandfather Stroke: N/A Diabetes (Type I or II): Maternal Grandfather (Type II) Blood disorders: N/A Cancer (breast, colon, other): Maternal Great Aunt (colon cancer), Great Aunt & Uncle (unknown cancer), Paternal Aunt (breast cancer) Sickle cell anemia: N/A Arthritis: Maternal Grandmother (rheumatoid arthritis) Asthma: Brother Other respiratory disorders: Maternal Grandfather (COPD) Drug or alcohol dependence: Maternal side (alcohol dependence) Obesity: N/A Mental illness: Paternal Seizure disorder: N/A Kidney disease: N/A Tuberculosis: N/A Other: Maternal Cousin (Parkinson’s), Maternal Grandmother (Parkinson’s) NURS 3308 Health History Template VI. Review of Systems: General overall health status: 1. Weight constant 2. No fatigue or lethargy 3. No sweating Skin, Hair & Nails: 1. Dermatitis on elbow 2. No excessive sweating 3. No bruising Health Promotion: Cream from dermatologist used for dermatitis Head: 1. No headaches; migraines once a month 2. No dizziness or vertigo 3. Eyes: 1. Near-sighted vision 2. No discharge from eyes 3. Health Promotion: Currently wears glasses/contacts Ears: 1. No earaches 2. No infections 3. Health Promotion: Nose and Sinuses: 1. Allergies in nose 2. No obstructions 3. Mouth and Throat: 1. No sore throat 2. No mouth pain or bleeding gums 3. Health Promotion: Neck: 1. No pain or limitation of motion 2. 3. Breast: 1. N/A 2. 3. Health Promotion (include for male as well): Axilla: 1. No tenderness or rash 2. 3. Respiratory System: 1. No chest pain 2. No Hx of respiratory disease 3. Health Promotion: Cardiovascular: 1. No chest pain 2. No CV problems 3. Health Promotion: Peripheral Vascular: 1. No edema 2. No numbness 3 NURS 3308 Health History Template 3. Health Promotion: Gastrointestinal: 1. Normal appetite 2. No GI upset or cramps 3. Health Promotion: Urinary System: 1. Urinate normal frequency 2. Normal color to urine 3. Health Promotion: Male or Female Genital System: 1. Testicular pain present: 3/10 2. Lump on right testicle. 3. Redness present on right testicle. Health Promotion (Male or Female): Perform testicular self-examination daily since symptoms have arose. Sexual health: (Deferred for this assignment) Musculoskeletal: 1. Hx of arthritis in family 2. No muscle pain 3. Health Promotion: Neurologic: 1. No Hx of seizures 2. Normal coordination, no disorientation 3. Health Promotion: Hematologic: 1. Normal bleeding 2. No blood transfusion reactions 3. Endocrine: 1. No hx of diabetes 2. No change in skin pigmentation 3. Mental Status: Have you ever been diagnosed with depression, anxiety or mental illness? If so, describe. No, patient has not been diagnosed with mental illness. VII. Functional Assessment: Self-esteem, self-concept Education: Current Full-Time Student; Senior in University Financial Status: Dependent; Income adequate for lifestyle & health concerns Value/Belief System: N/A Activity/Exercise ADLs: Exercise, stretch, yoga, walking Leisure Activities: Video games, reading Exercise Pattern: Push-ups, pull ups, and ab workouts. Sleep/rest Sleep Pattern: Erratic; changes drastically Naps: Not recently Sleep Aids: N/A 4 NURS 3308 Health History Template Nutrition/Elimination 24-hour diet recall to include: Breakfast- Oatmeal Lunch- Macaroni, sausage Dinner- Pizza Snacks- Chips Fluids- Coffee, water, tea Voiding (usual pattern, times per day): 3-4 times per day Bowel (usual pattern): Once a day Interpersonal relationships/resources Social Roles: Gets along well with family, feels safe Support Systems: Mother, significant other, friends Time Alone: Pleasurable time alone Spiritual assessment (FICA)Faith: Describe your spirituality, faith or belief? NOTE: If patient says they are not religious, ask them what gives their life meaning and/or purpose Family gives patient’s life meaning and purpose. Importance and Influence: Does it influence how you think about your health? The patient states, “not really,”. Community: Are you a part of a faith community/congregation and receive support from them? No, patient is not a part of a faith community for support. Address and Application: Do you have specific spiritual needs that need addressing? Patient states that he needs to start meditating again. Coping and stress management Stresses: School, Financial Stressors Stress Relief Measures: Exercise, meditation, yoga, talk to friends Personal habits to include Tobacco (PPD): N/A Alcohol: N/A Street drugs: N/A Environment hazards Housing/neighborhood: N/A Workplace or Occupational Hazards: Driving Safety Seat Belt Use: YES Travel Outside of Country (where, when & how long): Never been outside of the country. Intimate Partner Violence: Do you feel safe? Yes. Have you ever been emotionally or physically abused by your partner or someone important to you? No. Occupational health: Healthy within workplace and school. VIII. Patient’s Perception of Health: How do you define health? How do you view your situation now? What are your concerns, or what are your health goals? Patient states that health is the health and wellbeing of your body & mind; a balance of your biological, spiritual, and mental needs to perform essential functions in daily life. Patient believes he is healthy, despite current concern. Patient’s health goals involve maintaining physical and mental health status, flexibility, getting fit, starting cardio. 5 NURS 3308 Health History Template IX. Based on the assessment data you have collected in this health history, list three prioritized health concerns you have for this patient: 1. Exacerbated issues in genital region. 2. Possible pain increase; need to monitor & reassess after treating chief complaint. 3. Parkinson’s history; take preventative precautions. 6