Youngstown State University

Department of Nursing
NURS 2643 Health Assessment

HEALTH HISTORY DOCUMENTATION FORM

Interviewer: Harlie Silberman Date of Interview: 10/06/2017

I. Biographical Data:
A. Client’s Initials: VLB

B. Age: 37 Birth Date: 02/23/1980 Birthplace: Jameson Hospital; New Castle, PA

C. Sex: Female Marital Status: Divorced Race: Caucasian Ethnic Origin: Irish, Welsh

D. Usual Occupation: Store Manager of Rite Aid

E. Present Occupation: Store Manager of Rite Aid

II. Source of Data: Valerie Lynn Bautista

III. Reason for Seeking Care (Chief Complaint): Check up

IV. Present Health (History of Present Illness): “I feel healthy right now,” stated by Valerie

V. Past Health (Past History):

A. Childhood Illnesses: Valerie denies any history of measles, rheumatic fever, scarlet
fever, and poliomyelitis, mumps, rubella, and pertussis. She adds that she did have
moderate outbreak of chickenpox at the age of 8 and has had strep throat numerous
times.

B. Childhood Immunizations: Valerie received the proper immunizations required during

the year of 1983: DTP & Polio (2 months old); Polio & DTP (4 months old); DTP (6
months old); MMR (12 months); and DTP (18 months & 5 years old).

C. Accidents or Injuries: Valerie explains that she fractured her left wrist in two places in
the spring of 2016. Recent auto accident on 09/15/2017; reported no unconsciousness,
no lingering headaches, or major wounds from the accident. Also, no history of
penetrating wounds, head injuries, or burns other than through sunbathing.

D. Serious or Chronic Illnesses: No history of asthma, diabetes, hypertension, heart

disease, HIV infection, hepatitis, sickle cell anemia, cancer, and seizure disorder. History
of depression and was diagnosed at the age of 15.
 E. Hospitalizations and Operations: History of only one hospitalization during childbirth at
Aultman Hospital in Canton, OH. Valerie stayed for 3 days after the delivery. Her
obstetrician was Dr. Chugtia. No history of any operations.

F. Obstetric History: Grav 3, Term 1, Preterm 0, Ab 2; occurred at the ages of 17 (1997) and
another at 19 (2000), and 1 Living . Normal course of pregnancy without complications.
Vaginal delivery; no complications regarding labor. Valerie delivered a male at 7lbs. 4oz.
The condition of the baby boy was healthy without complications. Valerie did explain
she had severe postpartum depression after childbirth, which lasted about 2-3 months.

G. Adult Immunizations: Valerie explains she received a TB shot in 2015.

H. Last Examination Dates: Valerie states that on 05/01/2017 she visited her PCP. Summer
of 2015 was her last dental exam. Valerie received a pap test in October of 2016. No
history of vision exam, hearing exam, ECG, chest x-ray, mammogram, stool occult blood,
and serum cholesterol.

I. Allergies/Reactions: Allergic to penicillin. History of the reaction resulted in anaphylactic

shock (difficulty breathing) including a rash as well. Seasonal allergies occur; symptoms
include runny nose, and sore throat.

J. How Would You Describe Your Health? “I am healthy and active,” stated by Valerie.

VI. Medications (Name/Dosage/Dosage Times): Buspirone 15 mg – take once a day as needed;

Paroxetine 20 mg- take one tablet daily. Advil 400mg – takes if experiencing aches and pains.
Melatonin 5mg – takes before bed sometimes to aid with falling and staying asleep.

VII. Family History (include family tree): see attached page

VIII. Social History, Culture, Religion, Education: Valerie explained that some hobbies of hers include
watching her son plays sports such as football, baseball, and basketball, and watching the
Pittsburgh Steelers on Sundays, and enjoys listening to music. She also enjoys spending time
with family and friends, and watching movies on Lifetime Network.

IX. Review of Systems:

A. General Overall Health State: Valerie has claimed she has lost about 20 pounds within
August, September & October of 2017 due to anxiety and stress. She also states she has
been experiencing fatigue, malaise and occasional night sweats, but denied symptoms
of fever, and chills.
B. Skin: History of psoriasis. Patient claims that her psoriasis has recently changed color
due to the weather change (white, flaky red). She explains that sun exposure helps her
psoriasis in alleviating symptoms of severe xerosis and pruritus. However, the patches
will not tan but will change to a pink color and be less irritated. Patient denies of change
in moles, excessive bruising, rashes or lesions. Valerie states she has two tattoos: one
on the lower lumbar region of her back, and another on the lateral side of her left ankle.

C. Hair: Valerie explains that hair loss or change in texture depends on how much psoriasis
is on her scalp. Currently, Valerie is not experiencing severe psoriasis on her scalp
therefore no hair loss or change in texture is noted.

D. Nails: Valerie claims no excessive change in shape color, or brittleness, but has been
experiencing thickening and brittleness of her toenails and fingernails due to her
psoriasis over the past 5 years.

E. Head: Patient denies unusually frequent or severe headache, head injuries, and syncope
or vertigo.

F. Eyes: Valerie claims she has no difficulty with her vision: acuity, blurring, or blind spots.
Patient reports of no eye pain, diplopia, redness, swelling, discharge, watering, cataracts
or glaucoma. She denies wearing contacts or glasses.

G. Ears: Patient claims no issues with earaches, infections, discharge, or tinnitus.

H. Nose and Sinuses: Valerie denies discharge, any unusually frequent or severe colds,
nasal obstruction, nosebleeds, or change in sense of smell. She explains her allergies
bother her most during late September and early October. Symptoms include: runny
nose and sinus pain (temporal and maxillary regions)

I. Mouth and Throat: Valerie says she has mild bleeding gums and hoarseness or voice
change from stress and anxiety. She denied any mouth pain, lesions, tongue pain,
toothaches, dysphagia, tonsillectomy, or altered taste. Valerie does have frequent sore
throats during the late September and early October. Also, she got her tongue pierced
at the age of 18, but let it close in July of 2017.

J. Neck: Valerie denies any pain, limitation of motion, lumps or swelling, enlarged or
tender nodes, and goiters.

K. Breast: Valerie denies having breast pain, lumps, nipple discharge, rash, history of breast
disease, or any surgery on her breasts. Valerie also explains that she does not perform
self-breast examinations each month.

L. Axilla: Valerie reports of no tenderness, lumps, swelling, or rash in her axillae.

M. Respiratory System: Patient reports no history of asthma, emphysema, pneumonia,
tuberculosis, chest pain with breathing, wheezing, or noisy breathing, hemoptysis.
Valerie explains she has had a history with bronchitis contracting it about every 1 to 2
years. Valerie explains that when she runs for only a block she becomes short of breath.
Patient further tells that she experiences coughing in the morning when expectorating a
small amount of sputum that has a creamy color to it.

N. Cardiovascular System: Patient reports no chest pain, pressure, tightness or fullness,

palpitation, cyanosis, orthopnea, nocturia, paroxysmal nocturnal dyspnea, edema,
history of heart murmur, hypertension, coronary heart disease, or anemia. Valerie does
explain that she has dyspnea with exertion: walking 3 flights of steps.

O. Peripheral Vascular System: Valerie denies coldness, numbness and tingling or swelling
of her legs. Also, she reports no discoloration in hands or feet (bluish red, pallor),
varicose veins, intermittent claudication, thrombophlebitis, or ulcers.

P. Gastrointestinal System: Valerie explains she has a small appetite only eating once
during the day. After giving birth to her son in 2005, she had difficulty with hemorrhoids.
During the week of September 11, 2017, Valerie experienced a flare up of hemorrhoids.
Valerie denies of any food intolerance, dysphagia, heartburn, ingestion, abdominal pain,
pyrosis, nausea and vomiting, vomiting blood, history of abdominal diseases (liver,
gallbladder, ulcer, jaundice, appendicitis, and colitis), flatulence, frequency of bowel
movement, change in stool, constipation or diarrhea, black stools, rectal bleeding or use
of laxatives.

Q. Urinary System: Valerie claims she has nocturia about 2 nights per week. No frequency,
urgency, polyuria, oliguria, dysuria, hesitancy or straining, incontinence, history of
urinary disease (kidney disease, kidney stone, urinary tract infections), and use of Kegel
exercises. Color of urine is yellow. She claims of no pain in flank, groin, suprapubic
region or low back.

R. Male or Female Genital System: First menarche was in 1992 (12 years old). Valerie is on
Depo-Provera regarding birth control and in return does not have a menstrual period –
amenorrhea. Periods in the past, Valerie claims they were mild and regular. She reports
of no menorrhagia, premenstrual pain, or dysmenorrhea, or intermenstrual spotting.
Also, Valerie says she has no vaginal itching, discharge, and is not premenopausal.

S. Sexual Health: Patient explains she is not sexual active. Condoms are not used, no
dyspareunia, and contraceptives are used (birth control). She says she is aware of any
contact with a partner who has any sexually transmitted diseases such as gonorrhea,
herpes, chlamydia, venereal warts, HIV/AIDS, or syphilis.

T. Musculoskeletal System: Patient explains her Psoriatic arthritis in fingers, knees, toes,
low back and feet with additional pain stiffness. However, she reports of no swelling,
 deformity, limitation of motion, and noise with joint motion. No muscle cramping, pain,
weakness, gait problems, or problems with coordinated activities.

U. Neurologic System: Valerie denies history of seizure disorder, stroke, fainting, blackouts,
weakness, tic or tremor, paralysis, or coordination problems. Also, she states that she
has no numbness, paresthesia, memory disorders or mental dysfunctions such as
hallucinations. Valerie does explain that she has a history of depression relating to
nervousness, and mood changes.

V. Hematologic System: Valerie says she has no bleeding tendency of skin or mucous
membranes, excessive bruising, lymph node swelling, exposure to toxic agents or
radiation, or blood transfusion and reactions.

W. Endocrine System: Patient said that she has no history of diabetes symptoms (polyuria,
polydipsia, polyphagia), intolerance to heat and cold, change in pigmentation or texture,
excessive sweating, abnormal hair distribution, tremors, or need for hormone therapy.
Valerie further explained her current loss of appetite causing her to lose a significant
amount of weight through nervousness of stressful factors going on in her life. Also, she
explains that her thyroid was checked in 2010, but lab values were normal.

X. Functional Assessment:
A. Self-Esteem/Self-Concept: Valerie graduated from high school as her highest form of
education. She believes she provides an adequate income for her lifestyle and/or health
concerns. The patient further explains it is her hard work that has led her to succeed in
life.

B. Activity/Exercise: Valerie confirms her ability to perform ADL’s: independent with

feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, or
climbing stairs. She does not use a wheelchair, prostheses, or mobility aid. Valerie
described watching football to be a leisurely activity for her as well as spend time with
family and friends. Valerie does not exercise other than when at work by unloading
trucks and constantly being on her feet for long periods.

C. Sleep/Rest: Valerie claims she takes no daytime naps. She sometimes takes melatonin to
fall asleep. Also, on average she gets 6-7 hours of sleep per night.

D. Nutrition/Elimination: Valerie explains she eats only one time each day; less appetite
than normal. Normally she said she would eat 2 times a day and a few snacks in
between. No food allergies or intolerance. Valerie does not drink pop; she said she
started just drinking water in February. Valerie also does not drink coffee or tea. Usual
 bowel elimination is in the morning for the patient and urinates about 4x a day. Valerie
denies any problems regarding mobility, toileting, continence or use of laxatives.

E. Interpersonal Relationships/Resources: Valerie’s role in her family is a mom and the

main provider. Valerie said she gets along with family friends and co-workers. Valerie
says her support system would be her family and friends, especially her aunt. Time
spent alone according to the patient is pleasurable and relaxing.

F. Coping and Stress Management: Valerie’s stressors in life include family, financial issues,
and/or work. Specific stressors in the past year would probably due to some family
difficulties. Valerie says drinking alcohol helps her to relax and destress.

G. Personal Habits: Valerie smokes cigarettes, about a pack a day. She started at the age of
17 (1.5 PPD x 21 years). Valerie claims she quit smoking when she was pregnant with her
son, Cole in 2005. She picked up the habit again to compensate for her stressors after
she gave birth to her son. Valerie quit in 2015 as well but started up again June 2016.
Valerie does drink alcohol, on average 6-8 beers a night.

H. Environment/Hazards: Valerie just lives with her son, and has knowledge of her
neighbors. Valerie feels safe in the area, has adequate heat and utilities, access to
transportation, and uses a seatbelt when driving. Valerie is not involved in community
services, and hazards at work may include heavy lifting of boxes or climbing ladders to
stock shelves.

I. Occupational Health: Valerie is a store manager. She will open the store in the morning,
followed by various tasks necessary for a manager. For example, tasks may include
unloading truck, putting away truck, change seasonal aisles, scheduling, payroll, and
various managerial duties. Lifting and the repetitive motion of bending of the knees is a
hazard from Valerie’s job. She does not encounter asbestos, chemical, inhalants, and
wears no protective equipment. Valerie likes her job overall, but she dislikes mean
customers.