N174 Physical Assessment- Health History

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  • Topic: Health, Rheumatic fever
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  • Published : February 28, 2013
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UCLA SCHOOL OF NURSING
CENTER FOR THE HEALTH SCIENCES
LOS ANGELES, CALIFORNIA
IDENTIFYING DATA:
Name: Pt. # 1Date: 1/15/13
Address: 565 Gayley Ave., Los Angeles, CA, 90024Children: None
Sex: FOccupation: Student
Age: 20Religious Preference: Christianity
Date of Birth:Insurance: Private
Marital Status: SingleSource/Reliability: Self, seems reliable Race: Caucasian
CC: none
History of Present Illness:
Past Medical History:
Allergy: No seasonal allergies. Denies to drugs, food, or animals. Substances:
Meds: Ortho Tri-Cyclen (Norgestimate), acne medication (Clyndamycin Benzyl Peroxide gel) daily multivitamin. Denies illicit. Smoking: Denies.
Alcohol: 1-2 wine coolers/month.
Blood transfusions: Denies.
Preventatives: Childhood immunizations received. Last Tetanus - 2010 years ago (construction injury)
Trauma:Slip n’ Slide injury age 11. Fractured right pinky. All resolved without sequelae. Illnesses:
Childhood - Had common childhood diseases, rare Pityriasis Rosea, age 11. Chicken pox, age 8.
Denies diphtheria, rheumatic fever, etc. mumps, measles, rubella, whooping cough, heart murmur, seizures, joint problems, glomerulonephritis, scarlet fever, congenital defect, renal disease, other. Adult - Heart murmur, age 20. Seizure, age 20. Anemia, age 19. Low Ferritin levels, age 18. Given Iron supplements by Dr. Mattai @ UCLA Medical Center. Recovered fully, still on daily vitamin supplements. Surgeries-None.

Mental Health: PTSD, 2012. Denies problems.
Environment:Occupational – walks long distances, adverse weather conditions. Residences - Born, raised in CA.
Psycho-Social History
ADLS’s:
Sleep: requires 8-9 hours, receives 8-9; adequate, no problems. Exercise: exercises daily; 1 hour/day
Living Situation: rents studio/loft apt. Lives with friend of 3 years. Home 5 day periods a week. Visits parents’ home on weekends Work Environment: feels unsure about school environment, unsafe. Fairly antisocial, makes the occasional friend when the opportunity presents itself. Feels many students are immature. Gets along well with professors and TAs.

Relaxation: Reads a lot. Surfs the internet.
Hobbies: Reading, baking.
Nutrition: Used to be vegetarian. Currently eats from basic 4. Adequate milk/CA, veg/fruit, bread/cereal. Aware she lacks: meat/protein. Recently started eating meat again, couple months. previously a 9 year vegetarian. Excess occasional sweets, cheese, butter. Values/Beliefs/Stresses/Coping

Believes in commitment to family, hard work, being a good person and friend. Has unresolved issues about God/Religion. Major stresses are R/T ongoing family and financial issues. This puts stress on family life. Questioning future profession, minoring in education as resolution. Calls home regularly and talks to mother; fights more often with mother. Believes she’s doing well in school and tries to be a good student/daughter/sister. Relationships:

See Psych-Social-Values and work environment. Gets along with most people. Very close to mother and fairly close to step-dad who live in Cerritos. Fairly close to younger step-sister who lives/ studies in Maryland. Very close to half-brother who lives in Cerritos. Education:

High School diploma and currently attending UCLA, majoring in English and minoring in Education. Economics:
Finances are somewhat tight. Mother works for government and helps with school expenses. Family History:
PLACE GENOGRAM HERE
Family history positive for CA, CHD, Alzheimer’s, HTN, CVA allergies and arthritis.Family history of alcoholism, birth defects, blood problems/anemia, convulsions,diabetes, liver problems. Review of Systems

General: Wt. Present – 123 # lowest – 155 ( age 15) highest 100 ( age 17) Overall good health, “satisfied with weight” Has been same weight for 1-2 years. Denies fever, chills, sweats, weakness, fatigue, insomnia or nightmares. Skin/Hair/Nails: Hair appears healthy, occasionally greasy. Had acne as a youth and currently has...
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