Health history assignment part 1
Section 1: Biographic Data
N.V is a 46-year-old married Iranian woman, who currently is a full-time financial manager at BMW company. She speaks fluent English and does not require an interpreter.
Section 2: Source of History
The patient provides the information herself. The patient seems reliable, as she is alert and oriented.
Section 3: Reason for Seeking Care
The patient states, â€œI am really exhausted and want to get rid of my leg pain. I have severe pain in my thighs and legs and it started six years ago.â€
Section 4: History of Present Illness (HPI)
The patientâ€™s thigh and leg pain began six years prior to the interview. Her pain started following the birth of her second child. The patient has frequent episodes, the last being three days ago. It has never been resolved. It is specially located in the thighs and legs, sometimes includes back pain, and does not radiate to other regions. It mainly felt in the evening and at bedtime when the patient sitting or lying down. The duration is vary depending on the amount of activity that the patient has on that day, the longest being 48 hours and the shortest being 1 hour. The patient feels dull pain in the muscles that rates as 6 on the pain scale from 0 to 10. Lying down aggravates the symptoms. The patient has been using warm compresses and pressure massage to relieve pain. No treatments have been used. The patient denies having medical, surgical, or psychiatric conditions that are significant to the current condition.
Review of Related Body System- Musculoskeletal:
Patient reports having muscle pain in her legs. She sometimes experiences back pain as well. She feels the pain in the evening and at bedtime when the patient sitting or lying down. The patient denies cramps, weakness, coordination problems with activities, mobility aids, or assistive devices used. The patient denies arthritis, gout, or any pain, stiffness, swelling, deformity, or noise in her joints.
Health Promotion:Â Patient states that she walks about 500-1000 steps per day at work.
Section 5: Past Health
Patient has had mumps and denies a history of chicken pox, measles, rubella, pertussis, and strep throat. The mumps was lasts for two weeks and were treated by bed rest, plenty of fluids, and painkillers. There were no complications.
Accidents or Injuries
patient denies any accidents or injuries.
Serious or Chronic Illnesses
patient denies any serious illnesses. Denies history of asthma, depression, diabetes, hypertension, heart disease, HIV infection, hepatitis, sickle-cell anemia, cancer, and seizure disorder.
patient reports being hospitalized for nose surgery at Mahan hospital in 1996 for one night and two vaginal deliveries, at Cedars-Sinai hospital in 2001 and at Mission hills hospital in 2016. She was treated with ibuprofen for pain, and had no other complications.
OperationsÂ Patient has nose cosmetic surgery in 1996 at Mahan hospital in Tehran, Iran with Dr.Akbari. she stays one night at the hospital. She was prescribed pain medication during recovery.
The first pregnancy reached full term at nine months and was two weeks late before delivery. It was a vaginal delivery. The baby was a male, 7.2 Ib., and healthy. The second pregnancy reached full term at nine months and was one week late before delivery. It was a vaginal delivery. The baby was a male 7.5 ib., and healthy. Patient denies postpartum complications with both pregnancies.
Patient states that she has no record of previous immunizations, due to the records being lost.
Patient denies psychiatric history.
Last Physical Examination
Last examination was April 2022. Vitamin D deficiency and a borderline thyroid. No other abnormal finding.
Patient has allergies to eggplant and pepper, which cause rashes and itching. The patient notes do not use any medication for her allergy. NKDA.
|Name||Date||Dose||Reasons for Medication|
|Multivitamin||QD||500 mg, tablet, PO||Improve immune|
|Vitamin D-3||QD||25 mcg, 1 drop, PO||Improve D deficiency|
|Hairtamin||QD||250 mg, tablet, PO||Improve hair growth|
|Ibuprofen||PRN||600 mg, tablet, PO||Pain relief|
Patient denies taking aspirin, antacids, or cold remedies. Denies any home or herbal remedies.
Section 6: Family History
Mother, living, age 81, history of hypertension. Father, living, age 87, history of prediabetes. Sister, living, age 61, history of uterus cancer, and lung cancer. Brother, living, age 55, history of hypertension. Brother, living age 58, healthy. Brother, living, age 50, healthy. Maternal grandmother, deceased, age 65, bone cancer. Maternal grandfather, deceased, age 67, prostate cancer. Paternal grandmother, deceased, age 85, healthy. Paternal grandfather, deceased, age 72, history of diabetes type 2. Husband, living, age 52, history of hypertension. Son, living, age 20, healthy. Son, living, age 6, healthy.
Patient denies family history of coronary heart disease, stroke, obesity, blood disorders, alcohol or drug addiction, mental illness, suicide, kidney disease, and tuberculosis.
Section 7: Review of Systems (ROS)
General:Â The patient states that she considers herself to be healthy. She recently starts gaining weight. Patient deny any other illness, fatigue, weakness, malaise, fever, chill, sweat or night sweat.
SKIN, HAIR & NAILS:Â Patient denies history of skin disease, rashes or lesions, pigment or color change, change in moles, excessive dryness or moisture, pruritus, and excessive bruising. Recently, her hair started to fallen in the last 1 year ago.
Health Promotion:Â Patient states she uses sunscreen (UVA/UVB SPF 35) only on her face. Patient does not use sunblock on entire body daily. Patient Denies using indoor tanning beds. Patient denies performing monthly skin self-examination. Patient states she is in sun 2 to 3 hours a day.
Head:Â No abnormal findings. Patient denies severe headaches, head injuries, dizziness, and vertigo.
Health promotion:Â She always uses seat belt and drive through speed limits while driving.
Eyes:Â Patient states she does not have clear sight for far objects, but she never met any physician and does not try any treatment. Patient denies blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, history of glaucoma or cataracts.
Health promotion:Â Patient states fatigue weaken her eye sight too.
EARS:Â Patient denies any earaches, infections, discharge and its characteristics, tinnitus, or vertigo. No hearing loss or usage of hearing aid. Patient states she cannot recall her last evaluation with a physician.
Health promotion:Â The patient cleans her ears regularly. Patient notes she is exposed to light environmental noise.
NOSE & SINUSES:Â Patient states she had cosmetic surgery on her nose 27 years ago. She denies any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies, hay fever, or change in sense of smell
MOUTH & THROAT:Â Patient denies any frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, bad breath, history of tonsillectomy, or altered taste. The patient states her voice sounds hoarse sometimes.
Health Promotion:Â Patient brushes her teeth twice a day and flosses every night before bed. Dentist cleaning appointment once a year. The last dental visit was on 09/22, Dr. Mousavi, had no abnormal results including cavities.
Neck:Â No abnormal findings. Patient denies pain, limitations of motion, lumps, swelling, lumps, enlarged or tender nodules, goiters, and recent neck injuries.
Breast/Axilla:Â No abnormal findings. Patient denies breast pain, or unusual nipple discharge, or history of breast surgery or implants. She founded a lump in her left breast and diagnosed with fibroadenoma but states no treatment has been used for it.
Health Promotion:Â Patient does breast self-examination every month and last mammogram was in 2021, result shows no abnormal finding.
RESPIRATORY: Patient denies any lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), shortness of breath. She states she is exposed to a clean environment to breathe. The patient states she cannot recall her last TB test and chest X-ray.
Cardiovascular: Patient denies chest pain, palpitation, cyanosis, orthopnea, paroxysmal nocturnal dyspnea, history of heart murmur, coronary artery disease, heart failure, and previous MI. Patient states she cannot recall her last EGG or other cardiac tests.
Peripheral Vascular: patient denies coldness, numbness, tingling, swelling of legs, discoloration, intermittent claudication, thrombophlebitis, and ulcers. The patient has varicose veins in her right calf, and the patient states that she doesnâ€™t know when to get them.
Health Promotion: The patient reports some days has prolonged sitting or standing. The patient notes to always crosses her legs at the knees and not wear a support hose.
GASTROINTESTINAL:Â Patient denies any nausea, vomiting, hematemesis, dysphagia heartburn, reflux, indigestion, abdominal pain, abdominal disease, excessive belching or flatulence. She has bowel movements two or three times a day. She also denies any recent change in stool characteristics, constipation or diarrhea, black or tarry stools, rectal bleeding, rectal conditions such as hemorrhoids or fistula.
Urinary:Â Patient states she has no nocturia and urinates 3 times a day. Patient notes urine is a lighter yellow, no presence of hematuria. Patient denies dysuria, polyuria, oliguria, hesitancy, straining, narrowed stream, kidney disease, kidney stones, urinary tract infections and incontinence.
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