Elizabeth Bancroft
HEALTH HISTORY
DATE: 5/18/2020
NAME: JMB (name kept confidential)
DOB: 8/18/52
GENDER: male
RACE: Caucasian
RELIGION: catholic
MARITAL STATUS: widowed
OCCUPATION: retired
USUAL SOURCE OF CARE: PCP: Brian Miller
CHIEF COMPLAINT:
“My knee hurts”
History of Present Illness:
P (Provocative):
What causes your knee to hurt?
Not sure. it bothers me more going up and down the stairs. Sometimes when I
walk or ride my bike.
What makes it better or worse?
Carrying something makes it worse. Avoiding stairs helps.
What do you do for it?
Avoid things that cause it to hurt
Any meds?
No
Q (Quantity or Quality):
How does it feel ? dull pain , don’t notice any swelling ; sharper pain when carrying
things; sometimes I hear a rubbing or clicking but that is rare
Zero pain right now sitting down
Does it interfere with daily activities?
No doesn’t interfere with ADLs
Pain is same as last time I saw you
R (Region and Radiation)
Where exactly does it hurt and does the pain spread anywhere else?
front of knee sometimes goes down my leg to my shin
, S (Severity)
Pain on scale 1-10?
when I am not moving it is a 0/10, when it hurts it is a 6 on the pain scale. At its worse, have to
rest and stop carrying or stop the stairs.
Has the pain gotten worse or better since last time?
It is the same has been the same
T (Timing)
a year and a half ago, afternoon when carrying a lot of boxes. Gradually the pain got worse over
time. No specific time of day, only when I do stairs or carry things. maybe once a day. Doesn’t
wake me up at night. No correlation with time of year. Usually hurts for about an hour when I
aggravate it.
Anything else new happening or associated with this knee pain?
In the process of moving to a new house when it first happened.
Have you ever had this before?? No
Past Medical History:
Allergies: seasonal, dogs and cats, dust, mold
Medications (prescription): Singulair, pro air inhaler, meloxicam, dutasteride, Advair
inhaler
Medications (OTC): Prilosec every other day, flonase
Vitamins/Herbs/Supplements: centrum senior multivitamin
Last Exams: annual physical May 2019; PSA levels checked January 2020
Adult: increased PSA levels checked every 6 months (began August 2017) & asthma since childhood;
November 2013 diagnosed with primary skin cancer (basal cell)—treated and removed; checked every 6
months with dermatologist; osteoarthritis in left hip August 2019
Surgical: appendix removed 1999 (appendicitis and peritonitis); double inguinal hernia repair 2009; benign
tumor behind left ear removed February 2016
Vaccinations
Pediatric and adolescent vaccines does not recall.
Flu: August 2019
Pneumovax:
August 2019
Tetanus: patient recalls one years ago
HEALTH HISTORY
DATE: 5/18/2020
NAME: JMB (name kept confidential)
DOB: 8/18/52
GENDER: male
RACE: Caucasian
RELIGION: catholic
MARITAL STATUS: widowed
OCCUPATION: retired
USUAL SOURCE OF CARE: PCP: Brian Miller
CHIEF COMPLAINT:
“My knee hurts”
History of Present Illness:
P (Provocative):
What causes your knee to hurt?
Not sure. it bothers me more going up and down the stairs. Sometimes when I
walk or ride my bike.
What makes it better or worse?
Carrying something makes it worse. Avoiding stairs helps.
What do you do for it?
Avoid things that cause it to hurt
Any meds?
No
Q (Quantity or Quality):
How does it feel ? dull pain , don’t notice any swelling ; sharper pain when carrying
things; sometimes I hear a rubbing or clicking but that is rare
Zero pain right now sitting down
Does it interfere with daily activities?
No doesn’t interfere with ADLs
Pain is same as last time I saw you
R (Region and Radiation)
Where exactly does it hurt and does the pain spread anywhere else?
front of knee sometimes goes down my leg to my shin
, S (Severity)
Pain on scale 1-10?
when I am not moving it is a 0/10, when it hurts it is a 6 on the pain scale. At its worse, have to
rest and stop carrying or stop the stairs.
Has the pain gotten worse or better since last time?
It is the same has been the same
T (Timing)
a year and a half ago, afternoon when carrying a lot of boxes. Gradually the pain got worse over
time. No specific time of day, only when I do stairs or carry things. maybe once a day. Doesn’t
wake me up at night. No correlation with time of year. Usually hurts for about an hour when I
aggravate it.
Anything else new happening or associated with this knee pain?
In the process of moving to a new house when it first happened.
Have you ever had this before?? No
Past Medical History:
Allergies: seasonal, dogs and cats, dust, mold
Medications (prescription): Singulair, pro air inhaler, meloxicam, dutasteride, Advair
inhaler
Medications (OTC): Prilosec every other day, flonase
Vitamins/Herbs/Supplements: centrum senior multivitamin
Last Exams: annual physical May 2019; PSA levels checked January 2020
Adult: increased PSA levels checked every 6 months (began August 2017) & asthma since childhood;
November 2013 diagnosed with primary skin cancer (basal cell)—treated and removed; checked every 6
months with dermatologist; osteoarthritis in left hip August 2019
Surgical: appendix removed 1999 (appendicitis and peritonitis); double inguinal hernia repair 2009; benign
tumor behind left ear removed February 2016
Vaccinations
Pediatric and adolescent vaccines does not recall.
Flu: August 2019
Pneumovax:
August 2019
Tetanus: patient recalls one years ago
