HEALTH HISTORY

Date:

03/02/2015

Initials:

O.B

Age:

35

Date of birth:

09/02/1980

Birthplace:

Queensland

Gender:

Female

Marital status:

Married

Race:

Indigenous Australian and married to a Cuba male

Religion:

Catholic

Occupation:

School Teacher

Health insurance:

Aetna

Source:

Primary: patient gave all information

Reliability:

Dependable, attentive, conscious, capable of recollect precise information.

CURRENT HEALTH HISTORY

Reason for seeking care

Patients mentions that she is suffering from a shoulder pain and headache frequently since last week. She also states that the pain started after working for more than 10hours. She has a habit of checking all the student copies after the school gets over and continuously works till 7.30pm in the evening. The pain is localized at the backside of the head, eyes, and particularly constant, deep and sharp within the shoulder region, that she had to stop working. She mentions that when she prepares notes and study materials with the help of computer, the pain elevates more and she fails to bear the tremendous pain. During immense and unbearable pain she takes Tylenol pills of 500mg and goes to sleep to improve it. She marked her pain intensity as 8 out of 10. She also mentions that her headache was not linked with any kind of vertigo, dizziness and head injury. This medicinal administration helps her to get rid of her immense shoulder and neck pain but the healing effect remains for very little moment. But she is looking for a permanent healing effect. This is because she loves working as a teacher and just for this recoverable physical complication she does not want her work life to get affected. As per her, this shoulder pain and headache meant that her body was exhausted and she needs to take rest.

Health beliefs and practices

Spiritual, like to visit Church at least thrice a week

Health patterns

She believes that she is healthy. On a daily basis, she states her week activities that include morning walk, climbing stairs frequently a day, as she needs to change her classes as per the time schedule, driving home after work, washing utensils after dinner, and taking out the trash when needed. Her weekend activities include gardening, doing household tasks, like washing, cleaning, preparing food, though she has a help-cook and her husband supports her in works she requires help.

Medications

She is not very fond of medicines but because of this unbearable pain she has started taking Tylenol (500 mg), and this medicine is not prescribed by any of the physician. She also states that in case she feels acidity she consumes Gelusil antacids.

Health goals

Her health goal is to be healthy, and be physically fit. She is overweight. Her weight is 187pounds and she wants to reduce her weight as, she feels it is important for her to be fit and fine. She states that she states that she has no fatigue, fever, malaise, weakness, sweats or chills. But she feels hot very frequent if the weather is pleasant also. As per her this is because of her over weight.

PAST HISTORY

Childhood illnesses

She states she had Varicella when she was 10 years old.

Immunizations

Childhood immunizations up to date

Medical illnesses

None

Hospitalizations

She has been hospitalized two times for her delivery.

Surgeries

There is a history of a surgery

Injury

There was no past of severe accidents or injuries, but she admits that she felt down quite often during her school days and got hurt badly. She used to be a good basketball player and was in her school basket ball team.

Blood transfusions

No blood transfusion

Emotional problems

None, she is alert, orient and able to express her and makes her own decision

Allergies

Client denies any allergies to medication, food, but little allergic to dust.

Use of tobacco

None

Use of alcohol

She used to consume alcohol occasionally but after her pregnancy she stopped consume alcohol occasionally.

Use of illicit drugs

Patient denies using illegal drugs, such as Marijuana, Cocaine, Amphetamines, LSD or Heroin.

FAMILY HISTORY

Father

She mentions that her father has complications of alcoholism

Mother

She states that her mother has high blood pressure, little cardiac complication but she is active, and she is 60 years old.

Grandparents

She states that her maternal grandfather died of brain cancer at the age of 75 years and his maternal grandmother and all her siblings had cardiac problems, problems of high blood pressure and Rheumatoid Arthritis (D’Amico & Barbarito, 2012). She also mentions that her paternal grandfather died because of Parkinson’s disease at the age of 84years, and paternal grandmother has common weakness

Husband

Patient mentions that her husband is 40 years old and is asthmatic.

Children

She has two kids, one girl, who is 8years old and a boy, who is five years old.

PSYCHOSOCIAL HISTORY

Occupational History

She states that she has been working as a teacher since she graduated in 1998. Her current place of employment is a private school. She mostly teaches high school children. She states that what she most like about her job is enjoying a very competitive salary, communicating with children of different ages and their family members, dealing with real world problems and being able to solve them. She likes spending time with children and educates them, as she knows this competitive world and she understands the importance of education for each and every individual (McCarthy, 2014). She also states that it is a dream comes true when she got this opportunity to teach in a school. She is really happy and loves her profession but sometimes long exhaustive hours make her feel ill and thus affect her life and her children. Prior her pregnancy the condition was little different but after she has become a mother of two little kids, she has to manage time from her busy schedule for her two little kids. But she always manages times for her kids so that her kids do not feel lonely.

Educational level

Bachelor degree in Education.

Financial background

She states that her financial status is good, and her income is adequate for her life style and health concerns.

Roles and relationships

She states that she is a good mother, protector, leader, and teacher at home. She is not only supports her family financially, but contributes to the spiritual, health and emotional well being of her family. Also, she says that she protects her self-esteem and self-worth as well as her husband’s, and she feels she gives 100 percent of herself to her family. She lives with her husband and her two little kids. She gets immense support from her husband as well as her kids. She likes keeping and maintaining communications with her students and their family members.

Ethnicity and culture

She is an indigenous Australian and her husband is from Cuba. She has got married at a very young age and that’s why she had to relocate to Cuba at a very young age. She has completed her graduation while being with her husband. Her husband is very supportive. Though she is from a different cultural background but does not have any kind of culture oriented misbelieves inside her. 

Family

She is close to her husband

Religious beliefs

Catholic

Self-concept

She is very joyful and feels relaxed about herself.

REVIEW OF BODY SYSTEMS

Skin, nails, hair

Skin: client denies skin problem. She has standard skin turgor. Her skin is clean, little oily and intact. Client denies any problem of skin diseases like: eczema, hives or psoriasis (McCarthy, 2014). Her skin is very sensitive to sun burn and hence, she uses sun screen lotion.

Nails: client denies any nail color variation or change in shape. She is very hygienic and does cut her nails frequently to keep them short. She believes that applying frequent nail paint is bad for nail health (McCarthy, 2014). Frequent nail paint hinders the nails from getting oxygen from air and thus changes nail color from white to yellowish. Additionally, she takes multivitamin to keep her nails strong and healthy.

Hair: She has straight long hair and no changes in hair texture noted.

Head, neck, related lymph

Head: client complain of having shoulder pain, headaches, but denies of dizziness, or head injury

Neck: Client accepts having shoulder and neck pain, denies having motion problem, swelling, goiter and tender nodes.

Lymph: no swelling or lumps of nodes. No movement limitation of or swollen glands.

Eyes

Client denies having visisbility problem, reduced acuity, blurring, eye pain, eye swelling, diplopia or watering, cataract or glaucoma. She mentions redness in eyes while headache is intense. Patient denies using glasses or lenses. She has healthy vision and proper eye structures. Patient has undergone no Glaucoma test.

Ears, nose, throat and mouth

Ears: She denies having ear infections, tinnitus, earaches or vertigo. She mentions that she does not have hearing loss. She takes no support of hearing aid. Client cleans her ears with soap.

Nose: Client denies having nasal obstruction, allergies, fever, nosebleeds, and sinus pain. But as she is prone to dust allergies she suffers from itchiness when she comes in contact with some dusty materials, like: old cotton materials or while she transfers some stack of old books from one room to another (Potter, Perry, Stockert, Hall & Ochs, 2013). Now-a-days she is also facing this problem when she is inside the school library and dealing with old books to refer for her study purpose. She starts sneezing and it sometimes takes time to get relieved. She denies having a change in her sense or severe colds.

Mouth and Throat: Patient denies any sore throat, throat pain, lesions in mouth, dysphagia, voice change, tonsillectomy or altered taste. She complains about her itchy throat when she suffers from dust allergy.

She has no gum bleeding problem when brushing her teeth. She brushes her teeth twice a day and often uses antiseptic mouthwash. She states that she flosses her teeth twice a week. She uses no prostheses, and her last dental checkup was a year ago. The dentist checked her complete denture and reported no dental problems.

Respiratory

She denies having asthma, bronchitis, pneumonia, emphysema or tuberculosis. She has no chest pain with breathing. She states sometimes she suffers from mild breathing shortness and as per her that is because of her overweight. Patient states that she experiences breathing shortness when she walks for more than 15 minutes. Patient mentions that her chest x-ray was 3years ago and no severe disease was found.

Chest and axillae

She denies nipple discharge, pain, rash, breast disease, or any surgery.

Cardiovascular

Client suffers from no presence of palpitations, precordial pain, dyspnea on exertion, cyanosis, paroxysmal nocturnal dyspnea, orthopnea, nocturia, and edema; hypertension, coronary artery disease, heart murmur or anemia. Patient states that she did not ever undergo an ECG test.

Peripheral vascular

Client denies any coldness, swelling of legs or arms, numbness or tingling, discoloration in hands or feet, intermittent claudication, varicose veins, ulcers or thrombophlebitis or ulcers. She mentions that her work sometimes involves long sitting, which varies from 4-5hours daily. She states that she occasionally crosses legs at the knees when long-term sitting and never wear support hose in these circumstances.

Abdomen

She mentions that she has good appetite, but she avoids eating to avoid weight gaining. She has no complaints regarding any food intolerance, nausea or vomiting, indigestion, dysphagia, heartburn, indigestion, pain associated with eating, pyrosis, abdominal pain, pyrosis, vomiting blood, or flatulence. She states that she has history of liver disease because she had Hepatitis B when she was 20 years old. She has no complaints regarding bowel movement daily. Patient denies discomfort on defecation. She denies having complications associated with bowel movements, constipation, rectal bleeding and diarrhea or black stools. She has no complaints regarding hemorrhoids, or fistula. She sometimes takes antacids.

Urinary

Client denies that she urinates almost 6 times in a day without any urgency. She denies having dysuria, polyuria or oliguria, straining, inconsistence narrowed stream and urinary disease. She states that her urine is clear and no blood is present in the urine. She does not have any complaint regarding burning sensation while urinating. To avoid urinary tract infections, she mentions that she drinks three liters of water per day.

Reproductive

Client has no pain or lesions, vaginal discharge or hernia. She mentions that she performs vaginal self-examination when bathing. She uses medicated cleanser or wash twice a day.

Musculoskeletal

Client denies having arthritis. She denies presence of pain, swelling, stiffness, deformity or noise with joint motion. But sometimes feels mild pain because of long term sitting. Additionally, she denies presence of pain, weakness, gait problems (Potter, Perry, Stockert, Hall & Ochs, 2013). She also states that sometimes she has back pain while remaining sitting for long hours. She describes that this pain is usually at the lower part of her back, and does not radiate to extremities. She says that this is a dull pain, which lasts for few hours and once she stretches her back, she feels comfortable. Pain sometime reappears when she is very tired after working continuously for several hours in a same position. Pain does not obstruct her from freely walking and moving, but she rests to have relief or sometimes takes a walk for a short period of time. Patient denies the presence of stiffness or history of disc disease. Patient states that she prefers going for a morning walk but fails to maintain regularity (D’Amico & Barbarito, 2012). She has no problem with motion on daily activities, such as feeding, grooming or dressing. She uses no mobility aids.

Neurologic

She has no history of stroke, seizure, black outs, weakness, tremor, paralysis or coordination problems. She has no numbness problem and memory disorder, nervousness, mood change, depression, or hallucination problems or mental health dysfunction.