Health History
Lori L. Lindsey-Clarkston
Lakeview College of Nursing
RN 201 Health Assessment
December 1, 2010

Health History
Date of History:  November 23, 2010
Biographical Data:  Client is a forty-seven year old married, non-denominational Christian Caucasian female, born in Danville, IL.  The client is currently employed by school district 118 as a secretary at the high school.  
Source and reliability of Historian:  Client able to give reliable history.  
Chief Concern/Reason for Seeking Care:  “Feeling discomfort, like fullness in my mid-chest and under my ribcage in the middle. I feel anxious and I am nervous because I had a heart attack a few years ago.”
HPI:  States was at work today and started to feel “fullness” constant in mid-sternal region of chest and epi-gastric region.  Started approximately two hours ago and did not get any better, so she felt she had better come in to see what was wrong.  States she was not exerting herself when the discomfort started, stated she was doing data entry at her computer she was sitting down.  She denies any relief with rest.  She also complains of some dizziness, nausea, and some discomfort in the right side of her neck.  Complains of feeling very anxious, she denies any shortness of breath or diaphoresis.  She has a history of stent placement in the right coronary artery in November 2007.  
PMH:  Status post myocardial infarction with stenting of the right coronary artery November 27, 2007.  Coronary artery disease, hyperlipidemia diagnosed at the time of MI.  Mild left ventricular hypertrophy diagnosed November 2007 at the time of heart catheterization. Ovarian cyst removal 1997.  
Immunizations:  Up to date
Blood Transfusions:  No
Hospitalizations:  Ovarian and uterine cyst removal 1997; acute myocardial infarction with stenting of right coronary artery November 2007.  
Accident or injuries:  None
Emotional Status:  No history of depression or mental illness, psychiatric therapy or medications.  
Allergies:  No known allergies
Current Medications:  Oral:  Metoprolol Er 50mg daily; Crestor 10mg daily; Plavix 75mg daily; Aspirin 325mg daily; Omega 3 fish oil 1000mg daily.
Patient/Family Social/Health History:
•	Lives with husband and four children ages 9, 11, 14 and 15 years old.  
•	Client expresses home life is peaceful and she is happy
•	Client expresses that she is looking forward to retirement with her husband and enjoying watching her children grow and she wants grandchildren in the future.  
•	Husband works full time in a factory
•	Husband and client both quit smoking after client MI in 2007.  Prior to quitting history of 1-1.5 packs per day smoker for twenty years.  
•	Denies any alcohol or drug use or history of any use.  
•	High school diploma no college education
•	Does not exercise
•	Attempts to follow a low fat diet
•	Father died suddenly age 58 years from myocardial infarction.
•	Mother died from myocardial infarction age 60 years.
•	One sibling, a brother living 50+ years old has diabetes mellitus type II
•	Patient has five other siblings with no health problems.
•	Patient: denies menopause.
Review of Systems:
General:  Fair.  Has been good since stent placement in 2007 but now she is not sure.  
Head/Neck:  Denies any headaches, syncope.  No history of CVA or TIA, seizure activity.
Skin/Hair/Nails:  Normal skin turgor and texture; denies any problems with hair or nails.
Eyes:  Denies any blurred vision or vision deficits.  Does not wear any corrective lenses or glasses.  Denies any glaucoma, cataracts or familial eye disease.  
Ears:  Denies hearing loss or use of hearing aids; no pain, discharge or vertigo present.  
Nose:  Denies any nasal congestion, frequent colds, or breathing difficulties through nares.  No history of broken nose.  
Throat/Mouth:  No change in voice, any hoarseness, frequent sore throats, bleeding or swollen gums.  
Lymphatic:  Denies any swollen lymph nodes or tenderness.
Chest/Lungs:  Denies any shortness of breath at rest or with activity.  Denies history of asthma, COPD, lung disease, no wheezing or history of tuberculosis.  
Heart/Blood Vessels:  Complains of feeling “fullness” in mid-sternal and epi-gastric region starting approximately two hours ago.  History of myocardial infarction with stenting of right coronary artery November 27, 2007.  States she does have high cholesterol, not sure how long she was diagnosed when she had her MI in 2007.  Denies any history of hypertension or congestive heart failure.  
Peripheral Vascular:  Denies any history of Deep Vein Thrombosis or edema.
Hematologic:  Denies anemia, no history of blood transfusions.  
Gastrointestinal:  Denies any problem with appetite.  No history of Gastro esophageal Reflux diagnosis.  Denies nausea or vomiting.  Bowel pattern normal usually daily, normal in color and consistency.  Has gained approximately seven pounds in the last year.  
Diet:  Monitors and attempts to follow low fat, low cholesterol diet.  Drinks diet cola, three to five daily, sometimes will drink crystal light, rarely drinks water.  
Endocrine:  Denies any thyroid disorders or liver problems.  Denies polyuria or polydipsia.
Genitourinary:  Denies any problem with urination, starting, stopping stream, or dribbling.  Denies any history of kidney stones, frequent urinary tract infections or hernias.  No history of sexually transmitted disease.
Reproductive:  History of uterine (outside of uterus) and ovarian cyst with removal of cyst in 1997 without complication.  
Musculoskeletal:  Denies any history of arthritis, decreased range of motion, or fractures.
Neurologic:  Denies any history of TIA, CVA, seizure disorder, migraines, or paralysis.  Denies any numbness, tingling, or weakness.
Psychiatric:  Denies any history of depression, schizophrenia, or psychiatric illness or treatment.  Does states she feels anxious at this time but has no previous history of anxiety disorder.