Health History Assignment

Biographic Data:
Name: Mr. M.C
Age: 49
DOB: 06/02/1965
Birthplace: Springfield, IL
Gender: Male
Marital Status: Married, 26 years
Race: Caucasian
Ethnic Origin: American
Usual/Present Occupation: Government Employee, Retired Master Chief in
the US Navy
Primary Language: English
Source of History:
Patient
Reason for Seeking Care:
I had a pain in my chest that just wouldnt go away, no matter what I did.
History of Present Illness:
Patient was admitted from Internal Medicine for further evaluation of a 1month history of chest pain with and without exertion. The patient reports
the pain as, livable, and an 8 on a scale of 0-10. The patient cant
determine any precipitating factors of the pain. Rest does not relieve the
pain. Pt. reports, it just comes and goes on its own. Patient has a history of
HTN but feels like he has it under control. The patient reports that he doesnt
remember when the pain started, it just hasnt gone away so he wanted to
check it out. He is very concerned about his cardiac health and would like
more information on maintaining good cardiac health.
Past Health:

Childhood Illnesses: Chicken pox at age 8. Denies mumps, red measles,

German measles, and whooping cough.
Accidents or Injuries: Broke middle 3 phalanges in Right hand; required
pins and setting- 1987.
Serious or Chronic Illnesses: Hypertension diagnosed at age 42. Psoriasis
diagnosed at age 38. Tinnitus diagnosed at age 47.
Hospitalizations: Denies
Operations: Cross-Eyed correction- Right eye- 6 months old; Lasik vision
correction- 1995; Vasectomy- 2001
Immunizations: Patient reports up to date. Last flu shot November 2014.
Last Examination Date: Physical- December 2014, December 2014, visionAugust 2013, hearing- August 2013, EKG- November 2013, chest x-ray- pt.
cannot recall.
Allergies: NKDA, NKA
Current Medications:

Micardis- 20 mg/day PO

Vital Signs:
BP- 138/82
Temperature- 97.9 F
HR- 63
RR-14
SpO2- 99%
Family History:
Mother: Deceased- 74- Cause of Death was hypertension
Father: Deceased- 95- Cause of Death was heart failure following a
myocardial infarction
Sister: 56 years old, hypertension

Maternal Half-Sister: 59 years old, healthy

Sister: 57 years old, hypertension
Paternal Grandmother: Deceased- 73- Cause of death was a myocardial
infarction
Maternal Grandmother: Deceased- 83- Cause of death was a stroke
Paternal Grandfather: Deceased- 76- Cause of death was a myocardial
infarction
Maternal Grandfather: Deceased- 82- Cause of death was an myocardial
infarction
Children: 3, all healthy: 18 yo female, 16 yo female, 18 yo male
*See end of health history report for genogram
Review of Systems:
General Overall Health State: Patient reports he is 205 lbs (93.2 kg) , and
60 ft. (72 inches) tall. Denies fatigue, weakness or malaise, fever, chills,
sweats, or night sweats.
Skin, Hair, Nails: Excessive dryness and flaking as it relates to the
pathophysiology of psoriasis. Denies skin diseases, rash, pigment or color
change, abnormal hair or nail growth.
Eyes: Wears reading glasses. When wearing glasses, denies any difficulty
with vision, eye pain, diplopia, redness or swelling, watering or discharge,
glaucoma or cataracts.
Ears: Tinnitus and mild hearing loss. Pt. reports the hearing loss doesnt
affect his daily living. Denies earaches, infections, discharge, vertigo.
Nose and Sinuses: Denies discharge, sinus pain, nosebleeds, nasal
obstruction, or change in sense of smell.
Mouth and Throat: Denies mouth pain, frequent sore throat, bleeding
gums, toothache, oral lesions, dysphagia, hoarseness or voice change,
tonsillectomy, or altered taste.
Neck: Denies pain or tightness, limitation of motion, lumps or swelling,
enlarged or tender nodes, goiter.

Axilla: Denies tenderness, lumps, swelling, or rash.

Respiratory: Chest pain with and without exertion. Denies history of lung
diseases, chest pain with breathing, wheezing or noisy breathing, shortness
of breath.
Cardiovascular: Chest pain with and without exertion. Positive for
hypertension; last BP was 138/82. Denies any retrosternal pain, palpitation,
cyanosis, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea,
nocturia, edema, hx of heart murmur, CAD, anemia.
Peripheral Vascular: Denies coldness, numbness and tingling, swelling of
legs, discoloration of hands or feet, varicose veins or complications,
intermittent claudication, thrombophlebitis, ulcers.
Gastrointestinal: . Denies any changes in bowel movement, appetite, food
intolerance, dysphagia, heartburn, indigestion, vomiting, hx of abdominal
disease, flatulence, constipation, diarrhea, black stools, rectal bleeding, or
rectal conditions. Patient reports having a bowel movement twice every day.
Urinary: Denies hx of UTIs, having to go frequently, having to go multiple
times at night.
Sexual Health: Patient is married. Denies any sexual difficulties.
Musculoskeletal: Back and knee pain. Back pain in lumbar region. Bulging
lumbar disk (pt. cannot recall which one). Denies hx of gout, stiffness,
swelling, deformity, limitation of motion, noise with joint motion, muscle
pain, cramps, weakness, gait problems, back pain, stiffness, limitation of
motion, disk disease. Patient reports walking at least 30 minutes per day, at
least 6 times per week for work.
Neurologic: Denies hx of seizure disorder, stroke, fainting, blackouts,
weakness, tremor, paralysis, coordination problems, numbness or tingling,
memory disorder, nervousness, mood change, depression, hx of mental
health dysfunction or hallucinations.
Hematologic: Denies any bleeding of skin or mucus membranes, excessive
bruising, lymph node swelling, exposure to toxic agents or radiation, or blood
transfusions.
Endocrine: Denies any hx of diabetes, thyroid disease, intolerance to heat
and cold, changes in skin pigmentation or texture, excessive sweating,

abnormal hair distribution, nervousness, tremors, or need for hormone

therapy.
Functional Assessment:
Self-Esteem, Self-Concept: Patient received an Associates Degree and
Bachelors Degree from Excelsior College with a major in Criminal Justice.
Patient is considered to be in the middle class. Patient is a nondemotional
Christian.
Activity/Exercise: Patient able to perform ADLs independently. Patient
denies any use of wheelchair, prosthesis, or mobility aids. Patient reports
walking for at least 30 minutes per day, at least 6 days per week for work
and additional work around the house and yard.
Sleep/Rest: Patient gets at least 6 hours of sleep each night. Denies any
changes in sleep patterns or use of sleep aids.
Nutrition/Elimination: Patient reports consuming pizza, diet Dr. Pepper,
and water within the 24 hours prior to his hospitalization. Pt states that this
menu is typical for him. Pt reports that he likes to grill and smoke meat and
his wife cooks meals on the stove top on average 6 times a week. Patients
finances are adequate for food. Caffeine intake- Patient reports an intake of
3 cups of coffee a day and 2 glasses of soda.
Interpersonal Relationships/Resources: Patient reports good
relationships among him and his family members. Patient reports his wife is
whom he normally turns to for support. Patient keeps in close contact with
his immediate family members and loose contact with other family. Patient
describes his time spent alone as relaxing and isolating but enjoys having
one of my dogs on my lap with me.
Spiritual Resources: Patient states that he is religious and spiritual, even
though he does not attend church every Sunday.
Coping and Stress Management: Patient states he has the normal stress
in his life as far as with his children, wife, and job. Patient reports he likes to
twirl his handlebar mustache to relieve stress.
Personal Habits: Patient denies any tobacco or street drug use.
Alcohol: 1-2 beers/month
Illicit or Street Drugs: Patient denies any drug use.

Environment/Hazards: Patient resides in a small, safe community. Patient

has no neighbors in close proximity. Patient has adequate heat and utilities
and access to transportation. Patient reports no hazards at his workplace or
home.
Intimate Partner Violence: Patient reports he has never been abused by
his partner.
Occupational Health: Patient reports working in a noisy environment, as he
works heavily with firearms but wears eye and ear protection as mandated
by OSHA.
Perception of Health:
Patient states he defines health as health. He doesnt think wellness plays a
part in determining health. Patient states that he knows there are areas of
his health he could improve on, but since retiring its been hard to focus on
his health.
Developmental Stage:
The patient falls under Eriksons generativity vs. stagnation stage of
development.

Summary Statement:
Mr. G.M is a 49-year old Caucasian male who appears alert and competent at
the time of examination. His reason for seeking care was chest pain that
ranked 8/10 with and without exertion. He is concerned he may have heart
failure or will soon have a myocardial infarction. The patient states he would
like to learn more about maintaining good cardiac health.

Mr. G.Ms Genogram

W.M.- 76-

J.M.- 73-

L.J.- 82-

D.J.80s hx
of
stroke

U. W.W. M.70s
95- HF/ MI
leukemi
59,
K.A.-circle=C.L.*Square= male,
female, line through object =deceased.
healthy
Mr. G.M
56, HTN

M.J 83.-

N. M.- 74,
S.H - 57, HTN/
HTN Dementia