Health History and Physical Exam-Nur385 (revised).docx

Running head: HEALTH HISTORY AND PHYSICAL EXAM 1 Health History and Physical Exam Student’s Name Facilitator’s Name Date Indiana Wesleyan University HEALTH HISTORY AND PHYSICAL EXAM 2 Health History and Physical Exam Health History Due in Workshop 56 Date: 01/14/2020 Examiner: Torie Washington 1. Demographics: Client Initials: PM Birth Date: 10/23/1955 Age: 65 Gender: F Birth Place/Country of Origin Hermitage, PA, USA Race/Ethnic Origin: Caucasian Marital Status: Widowed Employer: Retired Occupation: N/A 2. Sources and Reliability: 3. Chief Complaint/Reason for seeking care: Intermittent chest pain 4. History of present illness: Patient states “I have been outside walking a few times this month and I have noticed that my chest gets tight and it’s hard to breathe when I do so. I have tried to stop smoking because I know it’s bad for me, but I get so anxious that I can’t stop. I get worried because I had a heart attack a few years ago.” PM reports that she takes a baby aspirin every day and takes her Lisinopril regularly. She does not take any other medications. 5. Past Health History: Patient has a history of a heart attack in 2017, she has two cardiac stents. She has a history of hypertension and takes Lisinopril for it. She also has a history of obesity but after her heart attack she reports that she lost 50lbs. She reports that she was diagnosed with diabetes 15 years ago but she does not take the medication she is supposed to anymore because she is controlling it “With her diet.” At her last doctors appointment though they found her BG to be high. She currently smokes half a pack of cigarettes a day. She had one C-section and a hysterectomy. Last Physical exam date 08/22/2019 Last dental exam July 2019 Last Vision exam unknown, pt states she had her vision checked at her last physical. Last hearing screen 08/22/2019- pt states her hearing was checked at her family doctor as well. Last ECG 12/14/2019 Last TB skin test unknown Last Chest X-Ray 12/14/2019 Childhood History: Chicken pox Accidents: Car accident in 2014, totaled her car but no injuries Serious or chronic illnesses/ Medical Problems Condition Onset Resolution/Treatment      Acute MI      While she was cooking dinner in 2017      Pt given Nitro and Aspirin in ER and had cardiac stents placed.      Hypertention      unk      Takes 20mg of Lisinopril daily      Diabetes Type 2      age 50      Pt prescribed metformin but does not take it