N174 Physical Assessment- Health History
UCLA SCHOOL OF NURSING
CENTER FOR THE HEALTH SCIENCES
LOS ANGELES, CALIFORNIA
IDENTIFYING DATA: Name: Pt. # 1 Date: 1/15/13 Address: 565 Gayley Ave., Los Angeles, CA, 90024Children: None Sex: F Occupation: Student Age: 20 Religious Preference: Christianity Date of Birth: Insurance: Private Marital Status: Single Source/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
CENTER FOR THE HEALTH SCIENCES
LOS ANGELES, CALIFORNIA
IDENTIFYING DATA: Name: Pt. # 1 Date: 1/15/13 Address: 565 Gayley Ave., Los Angeles, CA, 90024Children: None Sex: F Occupation: Student Age: 20 Religious Preference: Christianity Date of Birth: Insurance: Private Marital Status: Single Source/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