NURS 6760-Humagain_H&P

NURS 6760-Humagain_H&P HISTORY AND PHYSICAL Adult H&P Template Demographics: Name: PH Address: Wisconsin Age: 47 year-old Gender: Female Marital Status: Married Race: Black Culture: African American Religion: Christianity Occupation: Registered Nurse Source of information/Reliability: Co-worker CC/Present Illness “I am here for my annual physical/wellness check-up” History of Present Illness “I have been feeling well and I do not have any problems or concerns at this time.” Location NA Duration NA Exposures/excursions NA Characteristics NA Alleviating/aggravating factors NA Radiation NA 3 HISTORY AND PHYSICAL Treatments or remedies tried NA Severity (pain score or effect on ADLs) NA Allergies Penicillin—develops hives and rash. The patient denies seasonal and food allergies. Current Medications Multivitamins Vaccination History PH is update to date with her immunization. She had a negative Pap smear in Nov. 2017 and the last mammogram was done in Jan 2017 which was also negative. She will be getting her first colonoscopy next year. Flu Vaccine –received in October 2017 Past History-include the year if known The patient reports of uterine carcinoma diagnosed in 2015 and had curative intent surgery. Patient had gall bladder removed in 1999. The patient’s last physical was done in the month of March, 2017 and the results state she is healthy. Childhood Illnesses- Reports having Chickenpox as a child Medical Illnesses: The patient denies having any medical problems or concerns at this time. Hospitalizations: 1999 (gall bladder removal procedure), 2015 (diagnosis of uterine carcinoma) Surgeries: Curative intent surgery in 2015 and gall bladder removal in 1999 Injuries: Denies any apparent injuries Blood Transfusions: 2 Units of blood transfusion during her curative intent surgery in 2015 Emotional / Psychiatric problems 4 HISTORY AND PHYSICAL NA Social History The patient has been married for 18 years with no children. She works as a physical therapist in a rehab health setting. The patient is not a risk for HIV. The patient is sexually active with single partner. PH is Christian and denies any cultural or spiritual restrictions to care. Occupational history Education: Bachelors of Science in Nursing from Carrol University Housing (type): Two-storey single house, lives with her husband Recent losses- No recent losses Recreation- PH reports taking a walk, roller skating every Wednesday, shopping and listening to music for relaxation. Smoking history— denies current and previous use of smoking. Alcohol use- 1-2 glasses of red wine per week Recreational Drug use- Denies recreational drug use Nutritional Evaluation/24-hour history recallBreakfast-2 egg whites, oatmeal and a cup of coffee Lunch- Chicken Caesar wrap with a bowl of cream of broccoli soup Snacks- strawberries, almonds, 1 string cheese, 1 cup of coffee Dinner- pork ribs, mashed potatoes, steamed broccoli and carrots The patient reports of drinking approximately 2L water throughout the day. Exercise- PH reports of going to the gym