Youngstown State University

Department of Nursing

NURS 2643
HEALTH HISTORY DOCUMENTATION FORM
Date of Interview: October 22, 2019 Interviewer: Paige Meadows
I. Biographical Data:

Client’s Initials: B.S.

Age: 21 Birth date: 10/17/98 Birthplace: Pennsylvania

Sex: F Marital Status: Single Race: Caucasian Ethnic Origin: Caucasian

Usual Occupation: Student

Present Occupation: Student and Daycare worker once a week

II. Source of Data: Patient

III. Reason for Seeking Care (Chief Complaint):

Well-Visit

IV. Present Health (History of Present Illness):

B.S. describes current health as good. Had wisdom teeth removed on 10/8/19 but is
recovering well.

V. Past Health (Past History):

A. Childhood Illness/ Immunizations:

B.S. stated she was born with a heart murmur and a clubfoot (R), also had chicken
pox at 1 year of age. No other childhood illnesses such as measles, mumps, rubella,
pertussis, strep throat, rheumatic fever, scarlet fever, and poliomyelitis.
States she had measles/mumps/rubella, poliomyelitis, diphtheria/pertussis/tetanus,
hepatitis B, hepatitis A, and Haemophilus influenza type b vaccinations. Has not
 received a vaccination for chicken pox, shingles, pneumonia, or the flu. Used this as a
teaching moment to tell the benefits of receiving the flu vaccination.

B. Accidents or Injuries:

B.S. states broke right leg, tibia and fibula, before starting kindergarten.

C. Serious of Chronic Illnesses:

B.S. states no chronic illnesses such as diabetes, hypertension, heart disease, sickle-cell
anemia, cancer, and seizure disorders.

D. Hospitalizations and Operations:

B.S. states was born premature and had to stay in NICU from birth, 10/17/98 until
11/25/98. States was hospitalized at Pittsburgh Children’s Hospital at 7 months old to fix
bone in Right leg, and before 2 years old to fix the tendons in the Right leg. As a
newborn she received 2 blood transfusions because of a red blood cell count. She also
had her wisdom teeth removed on 10/08/19.

E. Obstetric History:

B.S. states no previous pregnancies and no yearly well-visits. Used this as a teaching
moment to tell about the benefits of going to a physician’s office and being checked.

F. Adult Immunizations:

B.S. states that she is up to date on adult immunizations but is unknown about the date of
them. She has never received a flu vaccination.

G. Last Examination:
 B.S. states she has not gone to a well-visit appointment since age 13 or 14. She had an
ER visit in March 2019 due to a hiatal hernia. B.S. states last eye exam was in January of
2019 and her last dental exam was in 2015 or 2016. She was seen by an oral surgeon on
October 08, 2019.

H. Allergies/ Reactions:

B.S. states has no known allergies to medication, food, or environmental agents.

How would you describe your health?

B.S. describes health as generally healthy.

VI. Medications Dose Dosage Times

1. Antacid (Famotidine) 20 mg 1x/day; 2x if needed
2. Ibuprofen 800 mg As needed

VII. Family History (includes family tree):

Family history is included with the family tree. The thread for B.S.’s family is
cardiac problems.

VIII. Social History, Culture, Religion, Education:

B.S. states she is in her 3rd year of college at Youngstown State University. She
states her religion as Agnostic, and she lives in a rural area.

IX. Review of Systems:

A. General Overall Health State:

B.S. states her diet and stress has led to a gradual weight increase over the past 2 ½ years.
She states no abnormal fatigue but is generally tired from school. B.S. states having no
weakness or malaise and experiences the occasional fever and chills. She states that she
occasionally has night sweats which she says could be caused by the temperature and
blankets used.
B. Skin:

B.S. states no presence of eczema, psoriasis, and hives. She states having no change in in
pigment or coloring and no changes in any moles. B.S. states experiencing normal dry
skin but nothing abnormal. She states having no pruritus, excessive bruising, rashes or
lesions. B.S. states using a moisturizing sunscreen on her face about every morning, and
she does not have excessive sun exposure. We discussed that sunscreen SPF 30 is the best
protective agent.

C. Hair:

B.S. states hair is blonde, oily, and a fine texture. She states she has had no abnormal loss
of hair.

D. Nails:

B.S. states nails are thick, do no break easily, she experiences no pain in nails, and has no
notable changes.

E. Head:

B.S. states the head has no bumps or lumps. She experiences dizziness when does not eat.
B.S. states that her glasses cause her to have headaches, rating a 3 or 4 on the 0-10 pain
scale every day. She states that she has had no previous head injuries.

F. Eyes:

B.S. states eye color is blue, and she wears glasses and contacts. She has astigmatism and
is near sighted. She states has issues seeing with the corrective wear. She states has
double and blurry vision. B.S. states she has pain in the eyes which leads to headaches
and gets blood shot eyes from strain. She states her last eye exam was in January 2019
and she has not had a glaucoma test.
G. Ears:

B.S. states she has good hearing. She states she occasionally hears a ringing noise. She
states has no infections, discharge, tinnitus or vertigo. She states she uses Q-tips as her
method of cleaning her ears.

H. Nose and Sinuses:

B.S. states she has occasional sinus infections and the occasional runny nose, she
experiences no pain or allergies. She states having no changes.

I. Mouth and Throat:

B.S. states it is easy to swallow with no pain, she states having no sores excluding just
having wisdom teeth removed on 10/8/19. She states having a thick voice in the morning
and bleeding gums and teeth when brushing. B.S. states having braces in elementary
school for 1-2 years. She states her last dental exam was in 2015 or 2016. B.S. states she
brushes her teeth two times per day, and she uses mouthwash.

J. Neck:

B.S. states she experiences an achy pain with the alleviating symptom being slouching
and there is no aggravating symptoms. She states she no limitation of motion, no
swelling, enlarged or tender nodes, or goiter.

K. Breast:

B.S. states she has general pain in the breast, says due to size. She states having no
lumps, nipple discharge, rash, or breast disease. B.S. states she has not had a
mammogram, but she does do self-examinations.
L. Axilla: B.S. states she experiences no tenderness, lumps, swelling, or rash.

M. Respiratory System:

B.S. states no history of asthma, emphysema, bronchitis, pneumonia, or tuberculosis.

States having no cough, wheezing, or hemoptysis. States having difficult breathing with
long walks or hills, states reason as “out of shape”. B.S. states coughing up sputum when
sick.

N. Cardiovascular System:

B.S. states no precordial or retrosternal pain. She states experiencing occasional

palpations with anxiety attacks. B.S. states no cyanosis. She states experiencing no
orthopnea, paroxysmal nocturnal dyspnea, edema, hypertension, coronary artery disease,
or anemia. B.S. states having nocturia, waking up between 4-6 am to void and
experiences pain with exertion. She states she was born with a murmur.

O. Peripheral Vascular System:

B.S. states no history of clots, ulcers, swelling, discoloration or varicose veins. She states
having leg numbness with prolonged sitting and feels cold based on weather. B.S. states
having no claudication, thrombophlebitis, or ulcers. She sits with her legs crossed often.

P. Gastrointestinal System:

B.S. states appetite is low on some days but high on others, some days she states she
forgets to eat. She states having GERD, eliminating features are antacids and aggravating
features are bell peppers. She states having diarrhea every morning since 6th grade stating
cause as anxiety and has once had blood in stool. She states experiencing constipation
after wisdom teeth removal. She states having occasional pain from hernia on left side.
B.S. states she has not had a serum cholesterol test or a stool occult blood test.

Q. Urinary System:
B.S. states having no frequency or urgency, dysuria, polyuria, oliguria, hesitancy or
straining, narrowed stream, urine color, incontinence. She states having no kidney disease
or kidney stones. She states having 2 urinary tract infections around age 13-14 years old
and was treated with antibiotics and experiences nocturia with waking up 4-6 am every
morning. B.S. says she experiences no pain in flank, groin, suprapubic region, or lower
back. We talked about the treatment for urinary tract infections such as wearing cotton
underwear.

R. Female Genital System:

B.S. states first menstrual period was at age 10, and her last start date as 10/21/19. She
states her menstrual period is regular and normally last 4-5 days. She states she
occasionally experiences heavy bleeding. B.S. experiences no amenorrhea, menorrhagia,
or intermenstrual spotting. She states experiencing premenstrual pain that varies but is
not debilitating. She states having occasional vaginal itching, and clear discharge. B.S.
states she has not had a gynecological check up or a Pap test.

S. Sexual Health:

B.S. states not being sexually active.

T. Musculoskeletal System:

B.S. states having no arthritis, gout, joint pain, swelling, muscle pain, muscle cramps,
weakness, gait problems or problems with coordination. She states having stiffness in
her fingers throughout the day, alleviating symptoms is cracking her fingers. She
states she has a clubfoot on her right foot and has limitation of movement in that foot,
with not being able to lift up and down or turn side to side, this causes her to not walk
as much because it causes pain that goes from her foot to hip to back. She states her
back makes noise when she leans back or turns over her shoulder. She states her
general pain as a 2 or 3 on the 0-10 pain scale with the pain varying in different
locations. B.S. states she walks between 1-2 miles per day.

U. Neurologic System:

B.S. states no history of seizure disorder, stroke, fainting, or blackouts. She

experiences no motor function weakness, tremors, paralysis, coordination problems,
or any memory disorders, mood changes, history of mental health dysfunction or
 hallucinations or any recent or distant disorientation. She states having numbness and
tingling on hand and feet if she sits on them for a prolonged time or if her hand are
lower for extended time. B.S. states she has anxiety and depression. I used this as a
teaching moment to tell about places on campus she can go and get help for free.

V. Hematologic System:

B.S. states having no bleeding of skin or mucous membranes, excessive bruising,

lymph node swelling, or exposure to toxic agents or radiation. She states she had 2
blood transfusions as a newborn and experienced no reaction from them.

W. Endocrine System:

B.S. states having no polyuria, polydipsia, polyphagia, thyroid disease, intolerance to

heat or cold, change in skin pigment and texture and excessive sweating. She states
she is unsure of her relation between her weight and her diet, she says she does not
eat a lot, but she is slowly progressively gaining weight. She states she can feel when
her blood sugar gets low. She states she experiences nervousness and anxiety on
situational basis. She states her hands always have a slight tremor with them
occasionally having a heavier tremor.

X. Functional Assessment:

A. Self-Esteem/ Self Concept:

B.S. states she is in her 3rd year of college and her income is adequate for her lifestyle.
She states her religious views as Agnostic and has no personal strengths or set values.

B. Activity/ Exercise:

B.S. states her activity is walking to class. She states her activity is independent and
good for independent daily life, she can tolerate activity. She states that she enjoys the
leisure activities of crochet, using her phone, and watching tv. She states she does not
have an exercise pattern.

C. Sleep/Rest:

B.S. states she gets 7-9 hours of sleep per night and she occasionally takes naps.
D. Nutrition/Elimination:

B.S. states her 24 hour recall of food as- breakfast: 2 bites of apple cinnamon oatmeal
with water, lunch: 3 parts of 4 part chicken and cheese quesadilla with Gatorade,
dinner: strawberry banana Naked drink, oatmeal and 1-2 bites of cinnamon roll,
snacks: 1 apple cinnamon bar and bites of oatmeal. Breakfast: none, lunch: 2 small 3
Musketeers, and 1 small Twix, dinner: grilled cheese, ravioli, zucchini and squash,
grapes, cantaloupe with Dr. Pepper, snack: none. She states this is a typical menu for
her and her appetite does not match her menu because she does not want to get up to
get food. She states she buys and prepares her own food as well as going to the
dinning hall. B.S. states her finances are adequate for food and she is the only one
present when she eats. She states she has no food allergies and drinks caffeine
through tea and pop depending on the day.

E. Interpersonal Relationships/ Resources:

B.S. says that her family gets along and she has a friend she can depend on in times of
struggles. She states that she is frequently alone and finds it isolating but sometimes a
little pleasurable.

F. Coping and Stress Management:

B.S. states that her stress level is okay, but if it gets to be too much it causes anxiety.
She states she does not share her feelings so the stress will sit in system until she
unloads it.

G. Personal Habits:

B.S. states that her last drink of alcohol was on 10/20/19 and she drank 2 cups. She
states she has never had a drinking problem and just drank for her 21st birthday
weekend. She states she has never smoked or done any illegal substances.

H. Environment/Hazards:

B.S. states she lives in a dorm room with one other person and she knows her
neighbors, she says she feels safe in her environment, and she has adequate heat,
utilities, and access to transportation. She states she is involved in clubs on campus.
B.S. states she has no environmental health hazards at the workplace or at home. She
states she uses a seatbelt and does not travel or have residence in other countries. She
states she does not have an intimate partner and is not afraid, hit, slapped, kicked,
 pushed, shoved, or otherwise physically or emotionally abused at home or in any
relation.

I. Occupational Health:

B.S. states that she does not have many occupational hazards, however when she
works once a week at daycare, she has the repetitive movement of picking up
children, but nothing to cause concern.