Running head: HEALTH HISTORY

Health History
Catherine Morris
Lakeview College of Nursing
	N201-Health Assessment	
February 24, 2011

HEALTH HISTORY
Health History
Date of history: February 19, 2011
Biographical Data
Patient is a 20 year old, single, white, female, student at Eastern Illinois University, currently employed at Finish Line. Patient was born in Granite City, Illinois and is Catholic. 
Source. Patient, seems reliable
Reason for Seeking Care. “Bumps at site of insulin injection.”

History of Present Illness.

Patient states that she has noticed “bumps” on her left thigh at the site of insulin injection. States that symptoms started two days ago. Describes the bumps as itchy. States that clothing irritates and makes the itching worse. Patient denies taking any over the counter medications.States that bumps do not spread and stay only on left thigh. Patient states that the bumps are worse after giving herself her insulin shot in the morning. On a scale of one to ten, patient rates this pain at a 3. 

Past History

General Health. Patient states general health is “OK”.
Childhood Illnesses. Chickenpox at age 4. No measles, mumps, croup, pertussis. No rheumatic fever, scarlet fever, or polio.
Accidents. 1. Auto accident, age 17, sister driving, head hit dashboard, no loss of consciousness, treated and released at Cardinal Glennon after 12 hours of observation.
Chronic Illnesses. Diabetes, type 1.
Hospitalizations. Age 18, Cardinal Glennon Hospital, diabetic ketoacidosis.
Obstetric History. Grav 0 Term 0 Preterm 0 Ab 0 Living 0.

Current Health Status

Current Medications. Humalog, 4/day, for 3 years, Novalog, 1/day, for 3 years. Metacycline, 1/day, for 3 years. No other prescription or over-the-counter medications.
Allergies. Penicillin, Sulfa, Nickel
Immunizations. Measles- mumps-rubella, polio,diptheria-pertusis-tetanus, hepatitis B, human papilloma virus. Last tetanus “probably freshman year of high school, 2004” Last TB skin test “probably junior high”, Last flu shot, October, 2010. 
Last Examinations. Physical every 3 months by endocrinologist. Last dental examination august 2010, last vision test November 2010, never had ECG or chest x-ray.

HEALTH HISTORY

Exercise/leisure. Believes self able to perform all ADLs; no problem in bathing, dressing, cooking, household tasks, mobility, driving a car, or work as cashier. No mobility aids. Hobbies are basketball, shopping, reading, exercising.
Sleep-Rest. Bedtime around 1 A.M. Sleeps 8 hours. No sleep aids.
Safety Measures. Believes housing is adequate, adequate heat and utilities, and neighborhood is for the most part safe. Believes home has no safety hazards. Uses seatbelt.
Alcohol/tobacco: First alcoholic drink, age 15. First intoxication, age 15.Drinking one to two times per week, two to three alcoholic drinks per occasion. No experienced blackouts, failed attempts to cut down on drinking, being physically sick in the morning after drinking, and being able to stop drinking after starting. No legal problems as a result. Denies use of street drugs. Denies use of cigarettes. Roommate smokes cigarettes.
Nutrition: 24 hour recall: breakfast, none. Lunch: chicken strips and low-fat macaroni and cheese, crystal light lemonade; dinner: salad, pickles, water. This menu is typical of most days. Eats lunch in a dining hall on college campus. Most dinners also in dining halls or fast-food. Shares household grocery expenses and cooking chores with roommate. Food intolerance: dairy

Family History

Patient states that family has a history of diabetes, high blood pressure, asthma, stoke, and arthritis. No family history of heart disease, bronchitis, hypertension, cancer, kidney disease, anemia, headaches, mental illness, seizure disorders, addictions, and tuberculosis. See attached genogram

Psychosocial History.

Interpersonal Relationships: Describes family life as extremely close. Many support systems currently. Gets along “great” with younger brother. Relationship with friends is “excellent”. Many close friends in sorority house. 
Daily Life. Typical day: Arises around 9 A.M., showers, spends most of day in classes, participates in intramural basketball in evenings 2/week, bed time around 1 A.M.
Coping and stress management: Identifies current stresses to be school and health. Considers her diabetes to be problematic.
Religious Beliefs. Raised as Catholic, believes in God, attends church when possible

Review of Systems

General Health. Reports usual health “OK”. No recent weight change, no fatigue, weakness, fever, sweats.
Skin. No change in skin color; pigmentation, or nevi. No pruritus, rash, lesions. Bruise on left thigh, bumped into while playing basketball game by opponent. No history of skin disease. Hair, no loss, change in texture. Nails, no change. Self- care. Goes to tanning bed 

HEALTH HISTORY

3/week during winter. Low exposure to sun in summer. Uses sunscreen as needed. 
Head. No usually frequent or severe headaches, no head injury, dizziness, syncope, or vertigo.
Eyes. No difficulty with vision or double vision. No eye pain, inflammation, discharge, lesions. No history of glaucoma or cataracts. Wears no corrective lenses.
Ears. No hearing loss or difficulty. No earaches, infections now or as a child, no discharge, tinnitus, or vertigo. Self- care. No exposure to environmental noise, cleans ears with q-tip 1/day.
Nose. No discharge, average of three colds per year, no sinus pain, nasal obstruction, epistaxis, or allergy. 
Mouth and Throat. No mouth pain, bleeding gums, toothache, sores or lessions in mouth, dysphasia, hoarsness, or sore throat. Had tonsils removed at age 10. Self care. Brushes teeth twice/ day, flosses 1/day.
Neck. No pain, limitation of motion, lumps, or swollen glands.
Breast. No pain, lump, nipple discharge, rash. Swelling, or trauma. No history of breast disease in self, mother, or grandmother. No surgery. Does not do self-examination.
Respiratory. No history of lung disease, no chest pain associated with breathing, wheezing, shortness of breath. Occasional evening cough, nonproductive. Lives in poorly ventilated room.
Cardiovascular. No cheat pain, palpatation, cyanosis, fatigue, dyspnea with exertion, orthopnea, paroxysmal nocturnal dyspnea,nocturia, edema. No history of heart murmor, hypertension, coronary artery disease, or anemia.
Peripheral Vascular. No pain, numbness, or tingling, swelling in legs. No coldness, discoloration, varicose veins, infections, or ulcers. Legs are equal in length. Self-care. Usual work as a cashier requires standing for five to six hours, wears support gym shoes.
Gastrointestinal. Appetite good with no recent change. Intolerant to dairy. No heartburn, indigestion, pain in abdomen, nausea, or vomiting. No history of ulcers, liver, or gallbladder disease, jaundice, appendicitis, or colitis. Bowel movement 1/day, soft, brown, no rectal bleeding or pain. Self-care. Take vitamin C. No use of antacids or laxatives. Diet recall-see Current Health Status.
Urinary. No dysuria, frequency, urgency, nocturia, hesitancy, or straining. No pain in flank, groin suprapubic region. Urine color light yellow, no history of kidney disease.
Genitallia. Menarche age 12. Last menstrual period February 7. Cycle usually q 28 days, duration 5 to 6 days, flow heavy first day followed by moderate flow, no dysmenorrheal. No vaginal discharge or itching, sores, or lesions.
Sexual health. In relationship now that includes intercourse. This partner has had unknown previous sexual partners. Uses condoms to prevent pregnancy. No use of birth control. Aware of no STD contact. Never been tested for AIDS. 
Muscoskeletal. No history of arthritis, gout. No joint pain, stiffness, swelling, deformity, limitation of motion. No muscle pain or weakness. No past bone trauma. Self- care. Uses support pads in gym shoes when exercising, playing basketball, or standing at work.
Neurologic. No history of seizure disorders, stroke, or fainting. No weakness, tremor, paralysis, problems with coordination, difficulty speaking or swallowing. No numbness or tingling. Not aware of memory problem, nervousness, or mood change, depression. HEALTH HISTORY

Had counseling for dealing with diabetes. Denies any suicidal thoughts or intent during adolescent years till now.
Hematologic. No bleeding problems in skin, excessive bruising. Not aware of exposure 
to toxins, never had blood transfusion. Use needles to administer insulin. 
Endocrine. Type 1 diabetic. No history of thyroid disease, increase in hunger, thirst, or urination; no problems with hot or cold environments; no change in skin, appetite, or nervousness. 

HEALTH HISTORY
Reference

Jarvis, C. (2007). The complete health history. In. L. Carter & D. Davis (Eds.), Physical exam & health assessment (pp.76-96). (5th ed.). St. Loius, MO: Saunders.