Client/Patient Initials: N.M Sex: Female Age: 79
Occupation of Client/Patient: Retired Registered Nurse
Health History/Review of Systems
(Complete and systematic review of systems)
Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications): Denies head injuries, convulsion, tingling, difficulty speaking or swallowing. Occasionally, has headaches, but states she takes Tylenol or Ibuprofen. Complains of dizziness when spends time working on her garden for too long in the sun. States that “She feels weak, sometimes, which has caused falls recently.”
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Denies head and neck injury, lumps/swelling, surgeries on head/neck. Occasional, headaches and neck pain from straining or sleeping in certain position.
Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications):
Denies eye pain, redness/swelling in eyes, watering, tearing, or injury to eyes. No history of crossed eyes. States she had cataract surgery with intraocular lens implantations. Wears eye glasses and gets eye exams annually. Denies any medication use for eyes.
Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications):
Denies earaches/pain, discharge from ears, history of surgery, environmental noise exposure, vertigo or medication for ears. States she is having difficulty hearing people on the phone, but denies difficulty hearing in person. N.M states frequent ear infections as a child, but none as an adult.
Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications):
Denies discharge, sores, lesions, pain, bleeding gums, or surgeries. Does not use any medications. Wears dentures and goes for dental exams every 6 months; brushes her teeth twice a day. States nosebleeds as a teenager, but none as an adult. Occasional sore throat, but states that it has not been serious.
Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications):
Denies skin disease or changes in a mole. States she is starting to see more age spots in her body, but denies rash or lesions. Hair has been getting finer and thinner. Nails are getting harder. States her skin is getting more dry and wrinkles; gray hairs. Denies any environmental hazards/exposures or medications.
Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications): Denies pain/tenderness, lumps, nipple discharge, rash, swelling, trauma, injury to breast. States she does breast self-exams every other month and has mammograms yearly.
Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications): Denies leg pain, swelling in legs or ankles, swollen glands or medications. States she has leg cramps occasionally and has varicose veins on both legs.
Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications): Denies chest pain, tightness, SOB, cough, swelling of feet or hands. States a family history of heart disease. States that she gets tired easily recently after doing too much work outdoors. She has hypertension and takes Lopressor twice a day…