Health History: Health Assessment Practicum

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Pages: 6

Health History

Audrey Reyes
Health Assessment Practicum
Dr. Moody
27 February 2017
Health History

Biographic Data
Name: V.W. Marital Status: Single
Address: 222 W. Danner Ave. Race: Caucasian
Phone: 123-45-6789 SS #: 123-12-1234
DOB: 07-01-1962

Source of History
The patient, Ms. W, who seems reliable.

Reason for Seeking Care
Patient states, “pain in my back and legs” of 13 hours’ duration.
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Patient states, “I cannot remember the last time I had an eye or dental exam.”

Allergies: Patient reports being allergic to Penicillin. Patient denies any allergies to food.

Medications: Tramadol, Lisinopril, B-12 shots monthly, Vitamin D and Calcium supplements. Patient reports sometimes taking melatonin as a sleep-aid. No other prescription or over-the-counter medications. Patient reports not able to remember past medication names.

Family Medical History: Mother died at age 62 of heart disease. Patient reports mother suffered from obesity, diabetes, hypertension, heart disease, alcoholism, and arthritis. Fathers medical history unknown. Patient denies family history of blood disorders, cancer, kidney disease, strokes, TB, seizures, allergies, and genetic disorders. Patient denies any history of mental illness.

Genogram or Pedigree including 3 Generations

Ms. W is the only child, mother died of heart disease at 62. She never personally knew her maternal grandparents but heard about her maternal grandmother after being told about her passing. It is unknown who or where her father is, and if he is alive. The paternal grandparents are also unknown but are old enough to be deceased by
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No food intolerance, heartburn, indigestion, pain in abdomen, nausea or vomiting. Patient denies history of ulcers, liver or gallbladder disease, jaundice, appendicitis, or colitis. Has bowel movement 2 times a day, soft, brown; no pain or rectal bleeding. Self-care: No use of laxatives or antacids.

Urinary: Urine color light yellow; no history of kidney disease. Patient denies history of dysuria, frequency, urgency, nocturia, hesitancy, or straining. No pain in flank, groin, or suprapubic region.

Musculoskeletal: Patient reports history of arthritis, joint pain, mild stiffness, limitation of motion, muscle pain, mild swelling, mild weakness in hands. No gout, or deformity. Self-care: Patient states, “I do not exercise, and I cannot lift objects very well.”

Neurologic: Patient denies history of seizure disorder, stroke, fainting. Has mild weakness in hands. No tremor, paralysis, problems with coordination, numbness, or tingling. No memory problems, nervousness, mood change, or depression.

Hematologic: Has bleeding problems in skin, excessive bruising. Patient denies exposure to toxins, never used needles to shoot drugs, never had a blood