Comprehensive Head to toe assessment on 20 year old male with right ear hearing loss, left eye ptosis. Example attachments are included.SampleHealthHistory.DraftFall14.pdfHEALTH

Running Head: HEALTH HISTORY 1

Health History

NURS 7180: Advanced Physical Assessment

James Doe

Dr. Shirley Comer

October 24, 2014

HEALTH HISTORY 2

Health History

Identification: AR, F, 58 years old

Informant: Patient, reliable source

Chief Complaint: “I run out of pain medication. I have trouble walking and taking a breath. My

pain is flaring up.”

History of Present Illness (HPI): Experiencing chronic muscular low back pain radiating to her

lower extremities (back of her thighs) for 3 years. Currently pain is 7 of 10- normally is 3 of 10.

Oftentimes, when pain gets uncontrolled, she suffers generalized pain from her back to her

upper and lower extremities, shoulders and head. Pain is constant and can be aggravated with

long hours of standing from work. However, it is controlled with her medication treatment

including Gabapentin 100mg three times a day, Ativan 0.5mg HS, Tramadol 50mg four times a

day, PRN and use of back brace support.

Past Medical History (PMI):

 Current medications: Gabapentin 100mg three times a day, Ativan 0.5mg every hour of

sleep, Tramadol 50mg four times a day, PRN, Hydrochlorothiazide 25mg daily, Amino acid

1 tablet twice a day, Omega-3 1 capsule three times a day, Glucosamine 1 capsule three

times a day, Vitamin C 1000mg daily, and Vitamin B12 1 capsule daily. All prescribed

medications are taken as ordered.

 Allergies: No known drug and food allergies.

 Surgeries: Tubal ligation, 1986, right upper chest excision of cyst, 1988, occipital head

laceration requiring 3 stitches from physical assault, 2006.

HEALTH HISTORY 3

 Hospitalizations/Non-surgical: Childbirth times 4 per vaginal delivery in the year 1981,

1982, 1985 and 1986.

 Trauma: MVA with no fractures, 2008 and physical assault resulting to occipital head

laceration requiring 3 stitches, 2008.

 Current and past medical problems:

Disease Dx date Resolved or continuing

Status

Hypertension 2006 C Well controlled with meds HTCZ

Hyperlipidemia 2006 C Diet controlled Chol 220 in 10/10

Scoliosis 2005 C Pain controlled by meds

Lung Nodule 2005 C Stable – yearly CXR

Pneumonia 2013 R Outpatient

 Infectious diseases: (received BCG vaccine as a child in the Philippines), requiring a yearly

chest X-ray). Last CXR 6/14. Had Varicella at age 8, no other infectious diseases.

Vaccine Received

Influenza 10-13

Pnemoncoccal none

Tetnus, diphtheria, pertussis (Td/Tdap)

2008

Varicella None had disease age 8

Human Papillomavirus (HPV) none

Zoster none

Measles, Mumps, Rubella (MMR)

Immunized as a child

Meningocaccal none

Hepatitis A none

Hepatitis B 2 doses in 2007

 Health maintenance:

HEALTH HISTORY 4

o Brisk walking for 20-30 minutes three times per week

o Compliance with healthy regime and prescribed medications

o Follows a heart healthy diet: low sodium and low cholesterol which include

healthy grains, fruits, vegetables, lean proteins, low intake of saturated and trans

fats and avoiding processed foods

o 24 diet recall- Breakfast: Toast with butter, coffee. Lunch: Tuna salad

sandwich, apple, starbucks’ cold coffee. Dinner: Chicken breast, Salad,

Chocolate cake. Snacks: pretzels, soft drink

o Routinely goes to the clinic for follow up visits (latest visit was 07/2014)

o Recent screening tests: Mammogram (2014), colonoscopy (2011), Pap smear

(2013); unremarkable tests results

o Yearly receives flu vaccine (Sept 2013)

o Received Tetanus vaccine in 2008 after the physical assault experienced

 Family History

Maternal Grandparents- Unknown- mother was adopted

Paternal Grandparents- Grandmother died age 88 of CVA- had CHF and DMII.

Grandfather died age 52 of MI-no previous history.

Parents- Mother age 72 with HTN. Father age 77 with Parkinson’s disease and HTN.

Aunt/Uncles- Aunt age 80 with HTN, CHF

Cousins- 2 Female ages 44, 50 in good health. 1 male age 55 with DMII and HTN.

Siblings- sister 54 in good health

Nieces/Nephews- Niece age 22 in good health

Children- Male age 25 in good health. Female age 20 with Down’s syndrome.

Grandchildren- Male age 3 mons- in good health.

HEALTH HISTORY 5

 Psychosocial History: Married with 4 children and living in the same household with strong

familial support to each other. Currently works as a registered nurse in Cook county clinic

with HMO insurance. Denies use of alcohol and illicit drug. Reports cigarette smoking in the

past for 2 pack-years, quit 1980. Drinks 1 cup of coffee in the morning before going to

work, brisk walking done 20-30minutes three times per week, follows a healthy regimen

however, reports sleeping 5-6 hours per night. Enjoys watching TV on her off days and goes

to church every Sunday. Mostly, at home when off at work; reports financial problems as

one of her life stressors.

 Review of Systems

General: Denies pain, fever, chills, malaise and fatigability. Reports no changes in

appetite and unexpected weight loss.

Skin, Hair and Nails : Reports no rashes, pruritus, bruising, dryness, lesions, skin cancer,

change in hair or nail texture, nail ridges or pigmentation. Uses hair dye to color graying

hair. Uses sunscreen regularly during the summer.

Head: Experiences intermittent headache when back pain is uncontrolled. Located in

bilateral temples, 4 of 10. Relieved with rest and Tylenol. Denies trauma, dizziness or

fainting.

Eyes: Last eye exam 9/11. Wears prescription glasses for reading and corrective lenses

on social occasions. Denies vision or visual field changes, diplopia blurring, burning,

discharge dry eye, cataracts, or glaucoma.

Ears: Last hearing exam, 5 years ago. Denies hearing problems or infections. Denis

tinnitus, pain, discharge, vertigo, or frequent ear infections.

HEALTH HISTORY 6

Nose: No history of epistaxis, obstruction, polyps, or sinus infections. Denies any

problems with smell and taste.

Mouth/Throat: Last dental exam 6/10. Complaints of bad breath and frequently uses

mouth wash or chew gum. Denies pain or difficulty in swallowing. Denies bleeding

gums, painful teeth, mouth ulcers/lesions, hoarseness, frequent pharyngitis, changes in

taste, snoring or sleep apnea. States brushes teeth twice daily and flosses daily.

Respiratory: Denies dyspnea, pain, sneezing, wheezing, sputum or hemoptysis. Denies

history of pneumonia, bronchitis, asthma. Reports history of smoking in the past for

2pack-years, quit 1980. Last chest X-ray, June 2010, revealed stable lung nodule

unchanged from previous 2009 CXR, requires a yearly chest X-ray for follow up r/t

receiving the BCG vaccine as a child in the Philippines .

Cardiovascular: No complaints of chest pain, orthopnea, dyspnea with or without

exertion, peripheral edema, murmurs, or palpitations. Reports controlled hypertension

while being compliant with prescribed medication. Stress test done 2009 was normal.

Peripheral vascular: Denies claudication and edema. No history of deep vein thrombosis

or non-healing wounds. Denies varicosities, cold or pale extremities.

Gastrointestinal: Denies changes in appetite and unexpected weight loss. Reports

eating a high fiber diet to maintain regularity in the bowel movement; Last BM 1-1-12.

Last colonoscopy, 2011, revealed colon polyps; removed and biopsy done with negative

malignancy, next colonoscopy will be done a year after. Denies dysphagia, heartburn,

nausea and vomiting, indigestion, abdominal pain, diarrhea or constipation. Denies

jaundice, or food intolerances.

HEALTH HISTORY 7

Gynecological: Reports age of onset of menses at 14 years old with monthly periods of

3-4 days with moderate flow. Gravida 4/Para 4/Abortions 0, living children aged 30, 28,

26 and 24. Reports childbirth per vaginal delivery without complications. Reports

menopause at age 55 years. Denies STDs. Performs breast self-exam once a month. Last

mammogram, 2010 and Pap smear, 2011, revealed negative result. States has on is

monogamous with husband and is satisfied with sex life.

Genitourinary: Denies frequency, hesitancy/changes in stream, dysuria, hematuria,

polyuria, polydipsia, nocturia, incontinence. Voids clear yellow urine several times/day.

Endocrine: Denies polyuria, polydipsia, polyphagia, glycosuria and temperature

intolerance, glycosuria, changes in hair, skin texture, fatigue, weight changes, or goiter.

Musculoskeletal: Complaints of chronic muscular back pain for 3 years. Pain rating is 5

of 10. Reports scoliosis since 2005. No limitations in the range of motion. No history of

gout and arthritis.

Hematologic: No C/o cold intolerance, fatigue, bleeding tendencies, bruising,

lymphadenopathy, or history of anemia.

Neurological: No history of head injury, seizure, syncope, weakness. Denies episode of

TIA or stroke. No loss of sensation, coordination or balance.

Psychiatric: Denies changes in mood, memory, sleep patterns, emotional disturbances.

No history of substance abuse.

Summary of Significant Findings:

Constant chronic muscular back pain for 3 years treated with Gabapentin 100mg three

times a day, Ativan 0.5mg every hour of sleep, Tramadol 50mg four times a day, PRN and use of

HEALTH HISTORY 8

back brace support as well as reported scoliosis since 2005; controlled hypertension and

hyperlipidemia with medication, diet and activity; ex-smoker for 2pack-years; intermittent

headache experienced during uncontrolled back pain; colon polyps however, removed during

colonoscopy screening. Familial history of hypertension, Down’s syndrome, diabetes mellitus,

CVA and CHF.

HEALTH HISTORY GUIDELINES

I. Subjective Data: (What the Patient Tells You; S of SOAP note)

Identification: Name, address, age, race, sex, referring care provider, etc. (For Class only

use initials, Sex, Age)

Informant: Self or relationship to patient, reliability

Chief Complaint (CC): Use patient’s own words and place in quotes; why are they seeking

care?

History of Present Illness (HPI): describes CC fully— Use OLDCHARTS acronym to fully

describe any abnormal reports. Include: diagnostic testing, home treatment, medical

treatment; risk factors and pertinent negatives as applicable

Past Medical History (PMH): Record positives/pertinent negatives of the following:

 Current Meds: Over-the-counter, home/folk remedies, and prescriptions including

PRNs only if used frequently: current and pertinent previous medications.

 Allergies: To medications, foods, environment and how they manifest

 Surgeries: Blood transfusions, anesthesia experiences, adverse reactions with

dates

 Hospitalizations/non-surgical with dates

 Trauma Injuries with dates

 Current and past Health Problems: record all disease processes including dates

of onset and current status of disease.

 Infectious Diseases: Ask about all active diseases and all immunizations

recommended by the CDC for pt’s age group. Health Maintenance (age/sex

appropriate):

1. Children: prenatal/birth history, immunization status, feeding/dietary

patterns, sleeping patterns; car seat/helmet use

2. Females: Last pelvic/PAP, breast self-exam/mammogram, colon; safety

measures

3. Male: testicular self-exam, prostate exam, colon; safety measures

 Usual state of Health with functional assessment: indicate the nature of living

quarters, ability to ambulate and perform ADL including meal prep. Laundry,

driving, use of assistive devices.

 Recent laboratory or diagnostic testing: give dates and results of recent testing

Family History: Age, current status, major medical problems of all blood relatives including

Grandparents, Parents, Siblings, Aunts/Uncles, Nieces/Nephews, Cousins, Children,

Grandchildren

Psychosocial History: Family/support structure, past/present occupations/ military service,

life stressors, risk factors/habits (alcohol, tobacco, caffeine, illicits, 24 hour diet recall,

exercise patterns, environmental exposures). Insurance, education level, religion, hobbies,

beliefs. Occupation.

Pediatrics: Grade, school success/problems, sleep/play patterns and developmental delays.

Domestic Violence History: history of violence or threats of violence. Threats to safety.

Review of Systems (ROS), (Always include pertinent negatives)

 General: Weight loss/gain; fatigue, weakness, appetite, fever/chills

 Skin, Hair & nails: Rash, pruritis, bruising, dryness, lesions, skin cancer, usual

self-care, hair loss, change in texture, nail ridges, nail color and texture

 Head: Trauma, headache, dizziness, fainting

 Eyes: Vision or visual field changes; corrective lenses; date of last exam;

diplopia, blurring, burning, discharge/dry eyes; cataracts, glaucoma.

 Ears: Hearing changes, tinnitus, pain, discharge, vertigo, frequent ear infections

 Nose: Change or loss of sense of smell, epistaxis, obstruction, polyps, sinus

problems.

 Mouth/Throat: Date last dental exam, bleeding gums, painful teeth, mouth

ulcers/lesions, hoarseness, frequent pharyngitis; Tonsils removed or intact,

changes in taste; snoring/sleep apnea.

 Respiratory (Resp): Chest pain, sneezing/wheezing, dyspnea; amount/color of

sputum; hemoptysis. History of pneumonia, flu, PPD or BCG (last chest X-ray)

 Cardiovascular (CV): Chest pain, orthopnea, dyspnea with exertion, nocturnal

dyspnea, murmurs, palpitations, peripheral edema.

 Peripheral Vascular: Intermittent claudication, peripheral edema, varicosities,

DVT history, cold/pale extremities, slow healing of distal limb wounds.

 GI: Dysphagia, heartburn, nausea/vomiting, hematemesis, indigestion, abdominal

pain (location, nature), diarrhea/constipation, stool frequency, consistency, color;

jaundice, fatty food intolerance. Date of last Bowel movement.

 Gyne: Age of onset menses—frequency, duration, flow, regularity,

dysmenorrhea; Date of last menstrual period. Contraceptive use/history;

Gravida/Para/Abortions (spontaneous/elective); complications during pregnancy

(DM, Eclampsia, Prematurity). STDs. Breast lesions, biopsies, galactorrhea. Age

of menopause/perimenopause; Hormone Replacement. Sexual history: Frequency,

# of partners, sexual orientation/satisfaction, dyspareunia.

 GU: Frequency, hesitancy/change in stream, dysuria, hematuria, polyuria,

polydipsia, nocturia, incontinence. Males: Lesions, discharge, STDs; sterility,

libido, impotency; Sexual history: Frequency, # of partners, sexual

orientation/satisfaction.

 Endocrine: Polyuria, polydipsia, polyphagia, temperature intolerances,

glycosuria, changes in hair, skin texture, fatigue, weight changes, goiter.

 Musculoskeletal (MSK): Joint pain/swelling; trauma, erythema, tenderness,

warmth; limitation in ROM, spinal/back pain/injury; history of gout, arthritis.

 Hematologic (Heme): Cold intolerance, fatigue, bleeding tendency, bruising,

lymphadenopathy; history of anemia

 Neurological (Neuro): Syncope, seizure, weakness; changes in coordination/

sensation.

 Psychiatric (Psych): Changes in mood, memory, sleep patterns, nervousness,

emotional disturbances, substance abuse.

Summary of findings: List findings in the history

Running head: Eye and Ear SOAP 1

Subjective:

ID: SM, female, 26

Source: Patient, reliable historian

CC: “My eyes are red and irritated. I think I have pink eye!”

HPI: Patient reports that she is generally in good health. She reports that she woke up

yesterday with sticky eyelids that further presented with yellow colored drainage. Denies pain to

eyes. Patient reports mild itching and burning and reports a sensation of grittiness. Reports

redness and swelling to her to her R eyelid. Reports an onset of yesterday 10.13.2016, location of

her right eyelid, duration of one day, aggravating factor of factor of rubbing her eye, and an

alleviating factor of a cold compress as needed. States that she would like her eyes and ears

checked.

PMH:

Current Medications: Hydrocortisone cream OTC as needed during eczema flare ups.

Last use: 9.13.2016 at 9am for a mild flare up on the forearms.

Disease Processes: PCOS well controlled by lifestyle management. Eczema is controlled

at most times but flares up from time to time. The last flare up was 9.13.16, it was a mild

flare up per patient’s report.

Hospitalizations and Surgeries: none

Allergies: No known drug, food, or environmental allergies.

FH: Non-contributory.

Running head: Eye and Ear SOAP 2

ROS: eye: Patient reports that she has 20/20 vision without corrective lenses. Denies blurred

vision, history of glaucoma, and diplopia. Denies history of cataracts. Denies tanning booth use.

Denies use of tanning booths. Reports mild blurring of vision when drainage is present. Ears:

Denies any pain to the ear. Denies presence of any hearing loss or drainage. Patient denies any

tinnitus or feelings of vertigo. Reports that she cleans her ears with a warm towel and denies use

of q-tips or hair pins to scratch ear. Denies use of hearing aid.

Psych/social: College student. Lives with parents and insured under their policy. Denies

tobacco, ETOH or illicit drug use. States is currently dieting- eating low carb. States is stressed

by school but feels she is coping well. Denies domestic or other violence concerns.

Immunizations: Up to date for all CDC recommended immunizations for her age. Last

Tdap-2016. Flu Vaccine Oct 2016.

Objective:

BP: 119/ 67 left arm P: 77 R: 15 Temp: 98.8 Height: 5’7 Weight: 185 Ibs BMI: 29

Eye and ear: Eyebrows are symmetrical, with fine hair. Palpebral slants symmetrical, no ptosis

noted. Orbital area is free of edema and sagging tissue. Eyelids are reddened and slightly

edematous. Eyelashes present evenly distributed with dried yellowish drainage noted.

Conjunctiva to right eye is reddened with drainage present, left eye is clear. Bilateral sclera are

white. Cornea covers the pupil and iris. Anterior chamber of eye is flat. Puncta of right eye is

reddened, left eye puncta is white. Pupils are symmetrical, round and 3mm in size. Snellen chart

used to assess visual acuity with 20/20 as result. Fields of vision full by confrontation. Pupils are

equal and reactive to light and accommodation. Convergence present upon assessment. Iris is

clearly defined. EOMs intact bilaterally. No nystagmus noted except with extreme lateral gaze.

Running head: Eye and Ear SOAP 3

No strabismus noted. Red reflex noted bilaterally. Optic disc margins well demarcated. No

nicking of the veins or arterial venous crossings noted. Macula noted lateral to optic disc. No

hemorrhaging or exudate noted on retina. External ear is free of drainage or tenderness. Acuity

good to whispered voice. Tympanic membrane presents as a pearly gray color free of bulging or

perforation. Cone of light noted at 5’oclock position in right ear and 7'oclock in left ear. Handle

of malleus noted at 1’oclock position in right ear and 11'oclock position in left ear. No

lateralization with Weber. AC>BC 2:1 with Rinne test.

Assessment: acute unilateral bacterial conjunctivitis.

Differential diagnosis: viral conjunctivitis, acute iritis, and acute closed angle glaucoma.

Plan: Gentamicin ophthalmic ointment- apply ½ ribbon to the affected eye bid

 If the infection does not subside, the next step would be to obtain and culture of the

specimen to choose a more appropriate antibiotic or to rule in a viral cause.

 Educate the patient on the highly contagious nature of bacterial conjunctivitis,

encouraging the avoidance of sharing toiletries and towels with family members to

prevent the spread of the infection.

 Encourage her to avoid rubbing her eye with her bare hands and touching her other eye or

other objects.

 Emphasis on hand hygiene.

Reference:

Watkinson, S. (2013). Assessment and management of patients with acute red eye. Nursing Older

People, 25(5), 27-34.

SOAP Notes Guidelines

Subjective:

ID: Initials, age and gender only

Source: Who is giving information and their reliability

CC: Must be in pt own words and in quotes. One to two sentences maximum.

HPI: Fully describe the acute symptoms. Use acronym OLDCHARTS to fully describe the

symptoms presented in the CC

PMH:

Current Medications: list all meds including OTC and Herbal. Give dose, route and frequency.

Don’t include meds used to treat the acute symptoms mentioned in the HPI. OK to say “none” if

none

Disease Processes: list all diseases with date of diagnosis. OK to say “none” if appropriate.

Hospitalizations and Surgeries: List all with dates. OK to say “none” if appropriate.

Allergies: List all with typical reaction when exposed. Include environmental and food allergies.

If none, you need to say “no drug, food or environmental allergies”.

FH: *Only complete if the complaint logically leads to questions about family history. Can be

abbreviated. If bit relevant, say “non-contributory”.

ROS: Use textbook to address hx r/t symptoms associated with the system. Don’t repeat HPI-

should be hx of system before onset of acute symptoms. Is ok to say “see HPI for acute

symptoms” if you feel the need to refer to the acute symptoms but is not necessary.

Psych/Social: Include issues regarding habits, insurance, coping, stress here. For Children

include a statement about their growth and development. If school age- indicate how they are

doing in school.

Immunizations/Infectious Diseases: *Only complete if the complaint logically leads to questions

about Immunizations and communicable diseases. Can be abbreviated. For Children- indicate if

current on their immunizations. OK to say “none” if appropriate.

Violence Hx. – Domestic or environmental violence- Bullying for school age

Objective: BP: ____ P: ___ R: ___ Temp: ___ BMI: ____Ht: ___, Wt ___lbs.

(Children only- Include CDC growth chart)

Include entire assessme

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