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Adult History

Adult History

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Published by Lizzy Pieper

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Published by: Lizzy Pieper on Jul 25, 2011
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01/01/2013

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NUR 405- Health Assessment Health History

Client Health History-7/3/2011 @ 1400
Chief Complaint: routine physical exam Source of History: Patient herself, seems reliable HPI: Marion P. is an 88 y/o Caucasian female, she appears healthy and to be around her stated age. Patient denies any health concerns today. She states she is pretty healthy and feeling pretty good for someone my age Medications: Pepcid (famotidine), 20 mg PO every night (GERD) Calcium + Vitamin D, 500mg/400IU 1 tab PO twice daily (supplementation) Cyanocobalamin, 100 mcg IM injection every month (pernicious anemia) Zyrtec, 5 mg PO daily PRN (seasonal allergies)

Allergies: Penicillin (skin rash) Past Medical History: - Pernicious Anemia (receives monthly B12 injections for this)
GERD/Acid Reflux Mild venous stasis to bilateral lower extremities Mild Seasonal Allergies Pregnancy x 3 (gravida 3, para 3)

Childhood Illnesses: - Measles, Mumps, Chicken Pox (pt unsure of dates) Past Surgical History: - Vaginal Hyterectomy ( 1970 s ) Family History:Father died of heart attack at age 70, Mother died of old age when in her 90 s.
Brother age 72 with history of lung CA (smoker). No family history of Diabetes or CVA.

Social History:
Nicotine: Pt. denies history of smoking/tobacco use. ETOH: 1-2 glasses of wine, monthly/rarely, special occasions only Recreational Drugs:Pt denies any current or historical use of recreational drugs. Exercise: Mostly sedentary, walks short distances with-in/around senior apartment complex Marital Status: Widowed, 3 adult sons (living & healthy) Employment:Pt is a retired from her job as a school cafeteria worker

Functional Assessment:
Self-Esteem/Self-Concept:Patient is a retired cafeteria worker, states she once attended nursing school briefly but admits she quit because I wanted to be at home to raise my children Patient states she

chills. swelling. Patient states she does not get much exercise and admits that she will occasionally take a short walk around the apartment complex but that is the extent of her exercise. or drink alcohol regularly. but no complaints currently. states she goes to bed around 10 or 11 pm and wakes between 6 and 8 am each day. Patient denies any concerns related to this. or redness. Patient states she has made rewarding friendships with some of the other residents in her apartment building. pt states I sure eat a lot of cookies! Patient tends to eat 3 meals a day and has one or two snacks. but does not feel compelled to attend services. Skin: Denies any rashes. Patient denies any concerns related to spirituality. Denies any recent changes in vision or problems seeing with glasses. stating after the kids grew up. Her children frequently check appliances for any needed repairs/maintenance. Patient denies any problems chewing or swallowing. Patient states her sons take her to the grocery store weekly. Denies any concerns r/t coping or stress management. Interpersonal Relationships:Patient has been widowed for 5 years. and she does get one meal delivered on business days by meals on wheels. and cards with the other apartment residents. . Head: Denies any headache. fever. Patient no longer drives. Patient denies any financial concerns. Spiritual Resources: Patient is no longer active in her church. She considers herself privately spiritual Environmental Hazards:Patient lives in a single-level apartment. has bifocals. use drugs. Pt. Denies any discharge .but in an apartment complex for senior citizens. syncope. we never went to church anymore. and values their support and friendship. or excessive dryness/moisture. doctor appointments. Patient admits that she sometimes falls asleep after lunch time and takes a afternoon nap Patient has no concerns related to sleep/rest. She has adequate heating/cooling/utilities. Sleep/Rest:Patient denies any difficulties staying or falling asleep. Pt reports runny nose with bouts of seasonal allergies. Patient states she doesn t cook like I used to and eats a lot of sandwiches or microwave dinners. has a emergency call cord system that she can activate for help in an emergency. sinus pain. or vertigo. Patient admits to having desert (usually cookies) after 2 of her meals on a daily basis. Nutrition/Elimination:In completing her 24-hour diet recall. All 3 of her adult sons live near-by and visit weekly or more often. Denies any skin conditions or suspicious moles or lesions. states I just gave it up. States I don t think I have much trouble hearing. Personal Habits:Patient does not smoke cigarettes. Patient still considers herself a lutheran. etc. considering my age Nose and sinuses: No reports of frequent nosebleeds. Review of Systems: General:reports feeling pretty healthy. Last eye exam 6 months ago. I never really liked to drive anyway Pt s children provide transportation to grocery store. Ears: Denies tinnitus/vertigo. dominoes. she lives alone. She frequently attends parties and activities hosted within the apartment complex. Denies weight loss/gain. or sweats. Eyes: Uses glasses for near & distance. Activity/Exercise:Patient lives in an apartment complex for seniors only and states she enjoys playing bingo. or changes in smell. pruritis.does not regret this and feels she and her husband raised their 3 boys to become successful young men.

although my short term memory is not as good as it used to be Patient denies any depression or mental health concerns. and reports that she elevates lower extremities frequently because her doctor told her this would be helpful for circulation in her lower legs. palpitations. Gastrointestinal: Patient reports having heartburn and acid problems but states that pill I take helps. or trouble swallowing. denies pain with movement. but does not report it having any major effect on her lifestyle. or cough. Female reproductive: Patient reports she had 3 healthy pregnancies and a hysterectomy a long time ago Her youngest child is 56. but admits I don t move as fast as I used to. no lumps. She states I get a B12 shot to help my body make blood cells. Patient denies any burning. Pt doesn t think she has ever had any heart testing done and states she thinks her cholesterol levels are Just fine. Patient states she occasionally has stress incontinence. No complaints of wheezing. or discharge. but I m old so what do you expect? Patient denies any pain that interferes with daily living. mouth pain. vomiting. or changes in appetite. CAD. No history of murmur. saying what for. Cardiovascular: Denies chest pain. discolored urine. Urinary: Patient reports that she thinks she urinates more frequently during the night that she used to when she was younger. Denies any constipation. No symptoms of diabetes reported. I m too old! but thinks she had a mammogram within the last year or two Respiratory: No history of lung disease. Pt denies pain. my joints ache sometimes. pain. States she no longer preforms self breast exams. swelling. or dyspnea on exertion. Neurologic/Psychiatric: Denies any history of seizures or fainting. last dental exam 2 months ago. or HTN. or pain with urination. diarrhea. Breasts: No lumps. No family history of breast CA. Pt denies ever having a blood transfusion. TB exposure. Musculoskeletal: Patient states I probably have arthritis. and I avoid foods that make it worse Pt denies nausea. Peripheral vascular:Pt states she has poor circulation in her lower legs. No history of hormone therapy. flosses regularly. Endocrine: Patient denies personal or family history of diabetes. Brushes 2 times daily. Hematologic:Pt denies any excessive bleeding/bruising. or dark and/or bloody stools. No history of thyroid disease or heat/cold intolerance. shortness of breath. Patient states I think my memory is pretty good. Denies sore throat. dysphagia.Mouth and throat: No complaints. or tenderness. because I guess I m anemic . wears ted hose and states she has discolored skin from poor circulation. I use a cane now Patient states she uses a cane because her gait is unsteady. Has own teeth. Neck: Denies any limitiations in ROM.

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