Youngstown State University

Department of Nursing

NURS 2643
HEALTH HISTORY DOCUMENTATION FORM

Date of Interview: 10/30/2020 Interviewer: Taylor Coy

I. Biographical Data:
Client’s Name: Kristie Hopp
Client’s Initials: KNH
Address: 1007 Newgarden Ave, Salem, Ohio 44460
Phone number: (352) 231 2859
Age: 21 years DOB: 08/19/1999 Birthplace: Jacksonville, North Carolina
Sex: F Relationship Status: Single Race: White Ethnic Origin: Caucasian
Usual Occupation: STNA and Student
Present Occupation: STNA at Auburn Skilled Nursing Home; YSU Nursing Student

II. Source of Data: From the patient (Kristie Hopp)

III. Reason for Seeking Care (Chief Complaint):

Wellness Check Up

IV. Present Health (History of Present Illness):

None.

V. Past Health (Past History):

A. Childhood Illness / Immunizations:

Hepatitis B immunizations at age 14. Measles, mumps, & Rubella immunizations and
HPV immunizations at age 15. Exposed and diagnosed with chickenpox at age 5. Never
has been vaccinated for pertussis. Has never been diagnosed with rheumatic fever,
scarlet fever, or poliomyelitis. Gets strep throat once a year around winter time.

B. Accidents or Injuries:
Lateral Pelvic Tilt injury caused inside the womb. Went to physical therapy at age 10 to
12. Had a concussion at age 12 during a basketball game. Was in a car accident that
damaged part of her lumbar age 18. No other fractures.

C. Serious of Chronic Illnesses:

 Chronic migraines that started at age 14. Patient does not have diabetes, hypertension,
heart disease, sickle-cell anemia, cancer, or seizure disorder. Patient was diagnosed with
scoliosis after car accident in 2018. Patient went to physical therapy to help with back
pain for 6 months. Sometimes has pain flare up in lower back that radiates to her rib cage.

D. Hospitalizations and Operations:

Patient had a Tympanostomy tubes, Shand’s Hospital in Gainesville, Florida; 2001.
Minimally Invasion Supra- Orbital nerve surgery, Shand’s Hospital, Gainesville, Florida
2015. Wisdom teeth extraction, location unknown in 2018.

E. Obstetric History:
G0 P0 Ab0 Liv0

F. Adult Immunizations:
Last tetanus, diphtheria, pertussis immunization in August 2020. Last Flu shot in
September 2020. Last tuberculosis skin test in August 2020.

G. Last Examination Date:

Most recent physical exam was in August 8, 2020. Last dental exam was in 2018. Last
eye exam was in 2011. Last hearing exam in 2015. Last electrocardiogram in 2018.
Patient has never had a chest x-ray.

H. Allergies / Reactions:
Patient is not allergic to any known medications or food. Patient is allergic to cats and
dogs. Reaction is nasal congestion and hives. Patient is allergic to the environmental
agent, pollen. Reaction is nasal congestion and SOB.

How would you describe your health?

Patient describes herself as a happy and energetic person. Patient doesn’t work out, but
does a lot of standing and heavy lifting at work.

VI. Medications Dose Dosage Times

1. Claritin (Loratadine) 10mg PRN

VII. Family History (include Family Tree):

Please see family tree for past family illness and diagnosis.

VIII. Social History, Culture, Religion, Education:

 Patient is currently enrolled at YSU in the nursing program. Patient is a Christian who
doesn’t go to church regularly. She likes to send her time with her friends or exploring
new cultures. History museum or theme parks are her favorite activities.

IX. Review of Systems:

A. General Overall Health State:
Patients present weight is 195lbs which is a 5lb increase from last year due to diet
and finical factors. Patient does not experience any fatigue, weakness or malaise,
fever, chills, sweats, or night sweats.

B. Skin:
Patient has no history of skin disease, no changes in any pigment or skin color, and
no changes in moles. Patient has no excessive dryness or moisture, no pruritus, no
excessive brushing, rashes or lesions. Patient frequently visits her hometown in
Florida, using sunscreen and limiting the amount of time she is outside to protect
her skin. In Ohio, she spends seven to ten hours outdoors weekly. Patient uses
lotion to keep skin from getting dry and sunscreen in the summer months.

C. Hair:
No recent hair loss or changes in texture.

D. Nails:
No changes in shape, color, or brittleness.

E. Head
Patient has chronic migraines that are more frequent in the summer then the
winter. Patient experiences dizziness, vomiting, and blurred visions when migraine
pain reach a level 7. Patient had a concussion at age 12 during a basketball game.
No other head injuries. No vertigo.

F. Eyes
Patient has no vision difficulty, eye pain, diplopia, redness or swelling, no
watering or discharge. Family has a history of glaucoma and cataracts surgery.
Patient has not been diagnosed or tested for glaucoma. Patient does not wear
glasses or lens. last vison exam was at age 10. She was diagnosed with anisocoria
after her head injury. Patient reports clear vision and has no trouble seeing things.
Eye drops are used when eyes become dry or irritated.

G. Ears:
Patient had frequent ear infections and earaches when younger. She was diagnosed
with “mild to moderate language deficit and severe speech deficit” as a result of
her inability to hear clearly in 2003. Patient had tympanostomy tubes in 2001 to
help with earaches and hearing. Patient currently has no earaches, discharge,
 tinnitus, or vertigo. Last hearing exam was in 2015 at Shand’s hospital. Patient has
no hearing loss and does not use hearing aids. Cleans ears by using q-tips. The
effect of her early hearing lost has made learning new words harder and trouble
with pronunciation. Environmental exposure is listening to loud music.

H. Nose and Sinuses:

Patient has no discharge or other characteristics, no nasal obstruction, nosebleeds,
or hay fever, or changes in sense of smell. Experiences a cold once a year. Only
has sinus pain when allergies become inflamed.

I. Mouth and throat:

Has no mouth pain, no frequent sore throat, bleeding gums, toothache, lesion in
mouth or tongue. No dysphagia, hoarseness or voice changes, or altered taste. No
history of tonsillectomy or use of prosthesis. Had wisdom teeth extracted in 2018.
Patients last dental check up was in 2018. Pattern of daily dental care is once daily
flossing and brushing of the teeth and tongue.

J. Neck:
No pain, limitation of motion, lumps or swelling, enlarged or tender nodes, or
goiter.

K. Breast:
No pain, lumps, nipple discharged, rash, or breast disease. Patient does SBE sitting
in front of the mirror once every six months. Patient has never had a mammogram.

L. Axilla:
No tenderness, lumps, or swelling, or rash.

M. Respiratory System:
No history of lung disease, no chest pain with breathing, wheezing or noisy
breathing; shortness of breath. Only experiences shortness of breath when
exercising. No cough, sputum, hemoptysis; no toxin or pollution exposure.

N. Cardiovascular System:
No precordial or retrosternal pain; no pain with palpitation; no signs of cyanosis;
no dyspnea on exertion; no orthopnea; no paroxysmal nocturnal dyspnea; no
nocturia, edema, hypertension, coronary artery disease, or anemia. No history of
heart murmur.

O. Peripheral Vascular System:

No coldness, numbness, tingling, swelling of the legs, discoloration in hands or
feet, varicose veins, intermittent claudication, thrombophlebitis, or ulcers. Does
thirty-six hours standing or sitting at work. Has a habit of crossing legs at knee.
P. Gastrointestinal System:
Patient has regular food intake and appetite; no food intolerance; no dysphagia; no
heartburn, indigestion, pain, pyrosis, nausea, vomiting, vomiting blood, history of
abdominal disease, or flatulence. Patient has frequency of bowel movements,
regular stool characteristics. No constipation or diarrhea, black stool, rectal
bleeding, or rectal conditions. Patient has never had cholesterol test or stool occult
blood.

Q. Urinary System:
Patient uses the bathroom 6-7 times a day. Patient experiences no urgency,
nocturia, dysuria, polyuria, or oliguria. Has no hesitancy or straining. No narrowed
stream. Urine color is clear to slightly yellow; no blood or cloudiness. Patient is
continence. No history of urinary disease; no pain in flank, groin, suprapubic
region, or lower back pain. Patient does not use Kegel exercise or any measures to
help with voiding or urinary tract infections.

R. Female Genital System:

Started menarche at age 12; Last menstrual period was on 10/19/20. Patient has no
virginal itching, discharged, no menopause signs or symptoms, or postmenopausal
bleeding. Never had a gynecologic checkup or Pap test.

S. Sexual Health:
Patient is currently sexually active with regular sexual satisfaction of patient and
partner. No dyspareunia; no changes in erection or ejaculation. Patient does not use
conception. Partner does not have any known or suspected contact with a partner
with a sexually transmitted disease or infection.

T. Musculoskeletal System:
No history of arthritis or gout, joint pain, swelling, stiffness, limitation or motion
or noise with joint motion, deformity. History of occasional lower and rib cage
pain from previous injuries. No cramps, weakness, gait problems, or problems with
coordinated activities, other pain, no stiffness, limitation of motion. Patient walks
over 10,000 steps a day. No effects of limits range of motion on daily actives. Has
no problems with grooming, feeding, toileting, or dressing & use of mobility aid.

U. Neurological system:
No history of seizure disorder, stroke, fainting, or blackouts. Regular motor
functions. No weakness, tic or tremor, paralysis, or coordination problems.
Sensory function is regular, no numbness or tingling. Mental status of patient is not
nervous, no mood changes, no depression or history of mental health dysfunction
or hallucinations.
 V. Hematologic System:
No bleeding of skin or mucus membranes. No excessive bruising, lymph node
swelling, exposure to toxic agents or radiation or blood transfusion and reactions.

W. Endocrine System:
No history of diabetes or diabetic symptoms, thyroid disease, intolerance to heat or
cold. No change in skin pigmentation or texture, excessive sweating. Has s regular
relationship between appetite and weight. No abnormal hair distribution,
nervousness, tremors, or need for hormones therapy.

X. Functional Assessment:
A. Self-Esteem/Self-Concept:
Patient is current enrolled in the YSU nursing program. The highest level of
education complete is an Associates Degree at Santa fe College when she was 18.
The patient is currently working as a STNA. Patient lives paycheck to paycheck
and must work over time to pay for her education and other living expenses.
Health concerns are her eating habits. Patient tends to eat out a lot and doesn’t
buy health foods, “because they are too expensive.” Patient is a Christine but
doesn’t actively go to church or practice the religion. Her strengthens are working
hard, supporting her family, and caring for her residents.

B. Activity/Exercise:
Patients usual daily activities are studying, cooking, cleaning, driving, working, or
hanging out with friends. She is independent of ADL’s; independent when
bathing, eating, cooking, dressing, etc. Patient is able to tolerate activities without
protheses or mobile aids. Leisure activities that she enjoins are studying or
hanging out with friends. She spends anywhere from 10-15 hours a week studying
and 5-7 hours a week hanging out with friends. Patient does not have an exercise
pattern.

C. Sleep/Rest:
Patient’s sleep pattern Sunday through Wednesday is 10 pm to 7am. Thursday
through Saturday the patient works night shift, making her sleep schedule 7am to
1pm. Patient doesn’t use any sleep aids and takes daily naps on Sunday through
Wednesday.

D. Nutrition/Elimination:
The patients last 24-hour food and beverage consumption were: breakfast 8oz of
water; Lunch was three tacos from Taco Bell and 16oz of Pepsi; dinner was
roman noodles with 8oz of water. This is a typical menu on the days she is off of
work. When she works, she tends to eat breakfast (fast food) and cook an early
dinner. Eating habits are eating out or cooking frozen or canned foods. Patients
current appetite is irregular and eats meals at random times. Patient and her
 roommate both buy food and take turns preparing. Finances are too low to by
healthy foods like fruits and vegetables. 4-5 days out of the week, patient eats her
meals alone. The other 2-3 days, patient eats with her fiancé or roommate. She
does not have any know allergies or food intolerance. Dailey intake of caffeine is
around 32-40 oz.

E. Interpersonal Relationships/Resources:
Patient does not have an active role in her family. Patient speaks to her sister
twice a month and talk to her parents once every three months. Patient
occasionally acts as a caregiver to her fiancé’s grandmother and gets along with
her in-laws. Patient says she gets along with her friends, co-workers, and
roommate. Her current support system is her significant other and roommate.
When there is an issue at work or personal, patient seeks advice from her
roommate. Patient also goes to her significant other for personal, work or health
concerns. Patient spends 2/3 of her time alone and finds is both pleasurable and
isolating.

F. Coping and Stress Management:

Patients currently stresses about her new home, work, school, and money. Patient
feels like her stress level has almost tripled from the previous year. Changes that
the patient has faced this year are a pandemic, buying a home, and starting
nursing school. Patient currently sees a therapist once a week for anxiety. Steps
that the patient takes to relieve stress are studying, going for walks, sleeping, or
hanging with friends.

G. Personal Habits:
Patients last alcohol consumption was yesterday night, 3 glasses. Patient does not
have a drinking problem. Typically drinks alcohol twice a month, each time
consuming 3-4 glasses. Patient is not a current smoker and has never smoked.
Patient has never tired marijuana, cocaine, amphetamines, or barbiturates or other
street drugs.

H. Environment/Hazards:
Patient lives and works with her roommate. Her roommate also has a 5-year-old
son. Patient knows her neighbor and works with her neighbor; lives in a safe area
with adequate heat and utilities. Patient has her own reliable car, which she uses
for transportation and even carpools with her roommate to “help with the
environment.” Patient is currently not involved in any community service and
wear proper personal protective equipment at work and in the community.

I. Occupational Health:
Patient is a STNA and loves her job. When asked to describe her job, patient said
“My job requires a lot of patience and understanding. I see a variety of patients
with different illnesses. Becoming an aide has help me understand the challenges
sick people go through on a daily bases, both inside and outside the nursing
home.” Patient is currently working through the pandemic and works closely
with other viruses and diseases. When asked how she felt with working with such
risk, patient replied, “it’s not about what they have, it about who they are.” Patient
wears personal protective equipment at work, does monthly educations, and daily
temperatures to monitor and prevent exposure. Patient does not have any health
problems that are related to work. When asked what she liked or disliked about
work, patient said “I hate being under staff not just because of the increased
workload, but the feeling of always being in a rush. Our residents are people and
sometimes it would be nice to sit down and hear their story.”