1 NURS 310 Adult Health History Rory Lang Date _______________________ Examiner ______________________________________ 9/20/23 BL 54 Date of birth __________ 2/22/1969 Patient name _____________________________ Age _____ Allergies ______________________ Advanced Directives Y / N : NKA Gender__________________ Do you want to designate a caregiver? Y / N : Male Source of information Patient/Chart Family /Healthcare team Reason for seeking care: _____________________________________________________ Lightheaded, diziness,dehydration _________________________________________________________________________ _________________________________________________________________________ History of Present Illness Describe History of Present Illness (in patient's own words) __________________________________ __________________________________________________________________________________ While at golf felt dizzy while bending down, urine is very yellow and fatigued __________________________________________________________________________________ __________________________________________________________________________________ Use the eight critical characteristics: Location, character or quality, quantity or severity, timing (onset, duration, frequency), setting, aggravating or alleviating factors, associated factors, patient’s perception (Jarvis pg 42-43). Hospitalized in last 30 days? Y / N If yes, describe: __________________________________________________________________________________ __________________________________________________________________________________ Have you been hospitalized outside of the United States in the last 6 months? Y / N If yes, describe: _________________________________________________________________ Current Medications List all scheduled, as needed and over-the-counter medications Medication Name Dose Form Frequency Special Instructions Ex: Aspirin 81mg Oral One time daily at 9:00am Don't crush or chew Crestor 20mg oral acetaminophen 500mg oral 1x daily, 8:00 pm q8hr PRN (Bickley, 2013, Jarvis, 2016) 09/2016 CG; Revised 09/16 DT, 08/23 SN, ED do not take 2 doses within 12 hours of eachother Do not take more than directed on package 2 NURS 310 Adult Health History Health History General health (describe) non-smoker, athletic, slightly over weight ___________________________________________________________________________________ ___________________________________________________________________________________ Circle all that apply Neurological : Dementia Cerebrovascular accident Aneurysm Brain tumor Seizure disorder Cardiovascular : Coronary Artery Disease Heart failure Hypertension Myocardial infarction Angina Pulmonary hypertension Valve disorder Heart murmur Congenital heart defect Respiratory : COPD Pneumonia Asthma Tuberculosis Gastrointestinal : Gastric ulcer GERD Diverticulitis Hepatitis Genitourinary : Urinary tract infection Benign Prostatic Hyperplasia Kidney disease Endocrine : Diabetes Adrenal dysfunction Thyroid dysfunction Pituitary dysfunction Integumentary : Eczema Psoriasis Hematologic/Oncologic : Sickle cell disease, Leukemia ,Lymphoma Cancer ______________________ Psychosocial: Alcoholism Substance abuse Mental illness Suicidal ideation Other medical history not previously listed ____________________________________________________________________________ Cholecystectomy ____________________________________________________________________________ Hospitalizations (reason, date) ____________________________________________________________________________ Emergency gall bladder removal 12/22/19 ____________________________________________________________________________ Surgical history (procedure, date) ____________________________________________________________________________ Cholecystectomy 12/22/19 , Rotator cuff 4/10/20 , Achilles tendon surgery 8/25/11 ___________________________________________________________________________ Childhood illnesses (illness, age) ____________________________________________________________________________ No childhood illnesses, other than the common cold ____________________________________________________________________________ Obstetrical history : Gravida _______ Term _______ Preterm ______ Incomplete ______ Para (Children living) ______ (Bickley, 2013, Jarvis, 2016) 09/2016 CG; Revised 09/16 DT, 08/23 SN, ED Text 3 Immunizations Have you had the influenza vaccine this year? Y / N If no, are you interested in receiving the influenza vaccine this visit? Y / N Reason for declination or ineligibility _________________________________________________ Have you received the pneumonia vaccine in the last 5 years? (if applicable) Y / N If no, are you interested in receiving the pneumonia vaccine this visit? Y / N Reason for declination or ineligibility _________________________________________________ Family History *Construct genogram on separate page Circle all that apply. Specify relative(s). Neurological : Dementia Cerebrovascular accident Aneurysm Brain tumor Seizure disorder Cardiovascular : Coronary Artery Disease Heart failure Hypertension Myocardial infarction Angina Pulmonary hypertension Valve disorder Heart murmur Congenital heart defect Respiratory : COPD Pneumonia Asthma Tuberculosis Gastrointestinal : Gastric ulcer GERD Diverticulitis Hepatitis Genitourinary : Urinary tract infection Benign Prostatic Hyperplasia Kidney disease Endocrine : Diabetes Adrenal dysfunction Thyroid dysfunction Pituitary dysfunction Integumentary : Eczema Psoriasis Hematologic/Oncologic : Sickle cell disease Leukemia Lymphoma Cancer ____________ Psychosocial: Alcoholism Substance abuse Mental illness Suicidal ideation Functional Assessment: Personal and Social History Highest educational level ______________________ Occupation _____________________________ College Electrician Home environment : Home Apartment Assisted living Healthcare facility Group home Other ________ Who do you live with at home? Self Spouse Family Other __________ Have you assessed your home for risks of falls and general safety issues? Y / N Do you feel safe at home? Y / N If no, do you feel safe going home today? Y / N *If no, complete domestic violence screening Describe concerns: ____________________________________________________________________ Do you have trouble caring for yourself or your home? Y / N Are there any activities that you need assistance or are dependent on others to perform? Y / N If yes, describe: ________________________________________________________________ Do you currently receive external health services? Y / N If yes, describe: ________________________________________________________________ Are there any spiritual, religious or other beliefs that influence your health or treatment? Y / N If yes, describe: ______________________________________________________________________ ___________________________________________________________________________________ (Bickley, 2013, Jarvis, 2016) 09/2016 CG; Revised 09/16 DT, 08/23 SN, ED 4 Functional Assessment: Health Promotion *Complete separate Health Promotion History* Describe your diet:______________________________________________________________ _____________________________________________________________________________ Low carb, High protein with occasional desserts when going out to dinner Have you had an unintentional weight loss in the last 3 months? Y / N If yes, complete nutrition screening assessment Do you have difficulty obtaining or eating a balanced diet? Y / N If yes, complete nutrition screening assessment Referral placed ⃞ Describe your typical exercise and frequency walking ___________________________________ daily, biking in summer time, golf every weekend Do you have any physical limitations that prevent you from getting regular exercise? Y / N If yes, describe ______________________________________________________ Do you use any mobility aids or assistive devices? Y / N Manual wheelchair Motorized wheelchair __________ In the past year, how often have you used the following? Never Walker Once or twice Cane Other _______________ Monthly Weekly Daily or almost daily Alcohol Tobacco products Prescription medications for non medical reasons Illegal or recreational drugs Have you ever smoked cigarettes or used tobacco products? Y / N If yes, what kind?: __________________________ Are you currently smoking? Y / N If no, has it been less than 12 months since you quit? Y/N Would you like a referral for tobacco cessation counseling? Y / N Referral placed ⃞ Do you currently use recreational drugs? Y / N If yes, what type? _____________________________ How often? _____________________________ Would you like help cutting down or quitting? Y / N Referral placed ⃞ Do you currently drink alcohol? Y / N Wine 4 glasses 1x per month If yes, what type? ________________ How much? ________________ How often? ________________ Would you like help cutting down or quitting? Y / N Referral placed ⃞ (Bickley, 2013, Jarvis, 2016) 09/2016 CG; Revised 09/16 DT, 08/23 SN, ED 5 Date _______________________ Examiner ______________________________________ 9/20/22 Rory Lang Patient name _____________________________ Age _____ BL 54 Date of birth __________ 2/22/1969 Health Promotion History Exam Last Date/Frequency Results Dental 12/22, every year cleaning Vision 9/23 prescription changed for near sighted vision Hearing Pap smear Mammogram Self breast exam Testicular self exam Prostate-specific antigen 9/23 negative Stool guiac 9/23 negative Colonoscopy/flexible sigmoidoscopy 9/23 negative Chest x-ray 9/23 no abnormalities found Electrocardiogram 9/23 no abnormalities found Lipid profile 9/23 serum triglcyerides elevated, high cholesterol - 408 mg/dL Fasting blood sugar 9/23 90 mg/dL Purified protein derivative (PPD) Sun exposure/Sunscreen use 6/25-8/30 sunscreen use, every time while at beach (Bickley, 2013, Jarvis, 2016) 09/2016 CG; Revised 09/16 DT, 08/23 SN, ED N/A Declined (Describe) 6 Date _______________________ Examiner ______________________________________ 9/20/23 Rory Lang Patient name ___________________________ Age ________ Date of birth __________ BL 54 2/22/1969 Dr. Lang Male Caregiver ____________________________ Gender_____________ Allergies ______________ NKA Immunizations Please give approximate dates for each immunization, if known: Series #1 DtaP/DT 1969 Tetanus boost N/A Polio IPV/OPV N/A MMR 1969 Hib N/A Hepatitis B N/A Pneumococcal N/A Varicella 9/23 Meningococcal N/A Influenza #2 10/22 (Bickley, 2013, Jarvis, 2016) 09/2016 CG; Revised 09/16 DT, 08/23 SN, ED #3 #4 #5 7 Date _______________________ Examiner ______________________________________ 9/20/23 Rory Lang Patient name _____________________________ Age _____ __________ BL 54 Date of birth 2/22/69 Allergies ______________________ Advanced Directives Y / N : NKA Review of Systems Circle all that apply. Describe (use additional paper) General : Fever Chills Night sweats Fatigue Unexplained weight loss Unexplained weight gain ⃞ Patient denies general symptoms Skin : Pruritus Rash Hair loss Worrisome lesion Moles Sweating Dry skin Nail change ⃞ Patient denies skin symptoms HEENT : Headache Dizziness Earache Hearing loss Tinnitus Vision change Eye pain/sensitivity Excessive tearing Eyeglasses/contact use Glaucoma Rhinorrhea Nasal congestion Postnasal drip Sinus pain Nosebleeds Hay fever Sore throat Mouth sores Hoarseness Toothache Bleeding gums Dentures ⃞ Patient denies HEENT symptoms Breast : Pain Lumps Discharge Implants ⃞ Patient denies breast symptoms Pulmonary : Cough Sputum Hemoptysis Shortness of breath Pain with respiration Wheezing Cyanosis ⃞ Patient denies pulmonary symptoms Cardiovascular : Chest pain Palpitations Dyspnea on exertion Orthopnea Paroxysmal nocturnal orthopnea Diaphoresis Syncope Heart murmur Leg edema ⃞ Patient denies cardiovascular symptoms Peripheral vascular : Claudication Varicose veins Phlebitis Coldness of hands/feet Leg ulcers Non-healing or slow healing wound ⃞ Patient denies peripheral vascular symptoms Gastrointestinal : Dysphagia Heartburn Change in appetite Food intolerance Nausea Vomiting Hematemesis Abdominal pain Bloating Flatulence Diarrhea Constipation Melena Jaundice Dark urine Bright red blood per rectum Change in bowel movements Hemorrhoids Hernia ⃞ Patient denies gastrointestinal symptoms (Bickley, 2013, Jarvis, 2016) 09/2016 CG; Revised 09/16 DT, 08/23 SN, ED 8 Genitourinary : Dysuria Urgency Frequency Hematuria Nocturia Polyuria Suprapubic pain Flank pain Incontinence Lesions Male : Hesitancy Dribbling Decreased force stream Testicular pain Testicular mass Testicular swelling Penile discharge Erectile dysfunction Female : Vaginal itch Abnormal vaginal discharge vaginal dryness Dyspareunia Sexual dysfunction Abnormal vaginal bleeding ⃞ Patient denies genitourinary symptoms Musculoskeletal : Joint pain Stiffness Back pain Restriction of motion Swelling Erythema Bony deformity Myalgia Muscle cramps Weakness Antalgic gait ⃞Patient denies musculoskeletal symptoms Neurological : Focal weakness Paralysis Numbness Tremor Seizure Syncope Gait disturbance Memory loss Aphasia ⃞Patient denies neurological symptoms Endocrine : Polyuria Polydipsia Polyphagia Heat/cold intolerance Tremor Lump in throat Unexplained weight change Hair changes ⃞ Patient denies endocrine symptoms Hematology : Anemia Easy bruising Swollen glands Bleeding of skin/mucous membranes Frequent infections Allergies Delayed healing ⃞ Patient denies hematologic symptoms Psychosocial : Anxiety Panic attacks Depression Mood changes Irritability Nervousness Decreased libido Eating disorder Sleep disturbance Suicidal thoughts Impaired judgment Hallucinations Confusion ⃞ Patient denies psychosocial symptoms (Bickley, 2013, Jarvis, 2016) 09/2016 CG; Revised 09/16 DT, 08/23 SN, ED 9 Health Interview Supplemental Documentation Tool Identify two actual or potential health problems or a need for health behavior modification using the subjective data collected during the health interview. (provide your rationale for problems identified/ need for health behavior modification) 1. _____________________________________________________________________ Fluid Volume Deficit/Dehydration - patient is experiencing fatigue, lightheadedness, diziness when bending down 2. _____________________________________________________________________ Anxiety - patient exhbits and experiences frequent nervousness, mood changes and irritabilty when encountering stressful or uncomfortable situations Write a plan that includes at least two elements that reflect intent for client teaching, referral or consultation for each identified health problem. Problem #1 Plan ________________________________________________________________________ Interventions will include identifying the cause of the patient's dehydration, supporting and encouraging oral fluid intake, rest when feeling dizzy, and consult ________________________________________________________________________ with a dietitian or nutritional services as needed. The client will verbalize he will increase oral fluid intake, with an addition of added electrolytes. The client will ________________________________________________________________________ monitor urine output as well. ________________________________________________________________________ ________________________________________________________________________ Problem #2 Plan _______________________________________________________________________ Goals for my patient can include that the patient will verbalize anxiety, concerns, and fears. The patient will identify factors that contribute to anxiety. _______________________________________________________________________ The patient will respond to relaxation techniques with decreased anxiety. Interventions that I will provide is to provide_______________________________________________________________________ adequate quiet time and decrease environmental stimuli, and educate how to deep breathe and step away from any activity when feeling overwhelmed. I also referred my patient to speak with a counselor if he _______________________________________________________________________ feels its neccessary, and to inquire about receiving medication with HCP if anxiety becomes unmanageable without pharmacology. _______________________________________________________________________ (Bickley, 2013, Jarvis, 2016) 09/2016 CG; Revised 09/16 DT, 08/23 SN, ED 10 Review of Systems Additional Notes General - Fatigue When did you begin to feel fatigued ? - I began to feel fatigued a few months ago, probably in July of 2023 What location in the body do you normally feel fatigue - I feel fatigue mostly everywhere and it feels like my body is tired. How long does your fatigue usually last? - My fatigue usually last for a couple hours, normally in the middle of the day until nighttime before I go to bed Can you describe your fatigue? - My fatigue feel likes weakness and I feel run down Does anything trigger the cause of your fatigue? - I mostly feel fatigued when I notice I am not drinking enough fluids and when I am tired. Can you tell me some things you do to relieve the feeling of fatigue? - When I feel fatigued I try to drink more water and get to sleep earlier so I am well rested for the next day. I also try to get out and walk when I can. Can you tell me the timing of your fatigue and how often it happens? - Over the past week I felt fatigued 5 out of the 7 days Can you describe the severity of the fatigue you are experiencing - My fatigue does not impact my daily life and is bearable, It just makes me feel tired HEENT - Headache When did you begin to feel a headache? - I began to feel headaches over the last year. What location do you feel your headaches? - I feel my headaches mostly around my forehead. How long does your headache usually last? - My headaches usualy last for a few hours. Can you describe how your headache feels? - When I get headaches, sometimes it throb and other days it feels like a dull pain What usually causes you to get a headache? - I normally get headaches when I don’t drink enough water throughout the day or when I did not get enough sleep the night before. How do you relieve your headaches? - I relieve my headaches by taking tylenol and rest. I also sometimes use the steam in my shower to help relieve the pain. How often do you get headaches? - I get headaches about three or four times a week. How severe do your headaches get? What would you rate your pain on a scale of 1-10? - Some days when I feel dull pain I would rate it at a 4, and on other days when my head feels like its throbbing, I would rate it as a 7 or 8. Psychosocial - Anxiety When did you begin to feel anxiety? - I began to feel anxiety about two years ago. Is there any specific body part that you could recognize a change in when you feel anxious? - I feel it usually in my stomach and my head can start to feel like its spinning. I also sometimes feel tightening in my chest. How long does your anxiety last? - It usually depends on the day, but I would say mostly when I am at work. Can you describe how you feel when you are anxious? - When I am anxious I feel nervous, jittery, and my mood changes very easily. I feel a sense of uneasiness in my stomach What usually causes your anxiety? - My job causes me the most anxiety. I am in charge of many peeople, and my responsibilities and other people’s actions make me feel anxious, especially because I am responsible of what happens on the job site. How do you relieve your anxiety? - Over the last year I have been meditating when I get home from work, which has helped me a lot. I also talk to my wife about the way I am feeling, that way I am not bottling my emotions inside. How often do you get anxiety? - Mostly everyday I wake up feeling anxious. How severe would you say your anxiety is, can you rate it for me on a scale of 1-10? - I would say it is more on the severe side, because I am in a constant state of worry. I would rate my anxiety levels as an 8 out of 10 on an everyday basis. (Bickley, 2013, Jarvis, 2016) 09/2016 CG; Revised 09/16 DT, 08/23 SN, ED
