This is an online one page posting for Health Assessment class:
Comprehensive Health History
Comprehensive Health History
This article is about a complete health history of a neighbor in California.
The name of this patient is Ms. Julie Colburn. She is an 83-year-old retired nurse. Currently, she is a patient who is reliable and an old California Pacific Medical Center (CPMC) chart.
Past Medical History:
Initially, her health was relatively good but with the usual childhood infectious diseases and no history of any rheumatic fever. Besides, she underwent yearly immunizations with the flu vaccine, and in 1996, she was immunized with Pneumovax. However, she became allergic to penicillin, which made her develop a diffuse rash after being injected with it 20 years ago. In 1980, she received four units of blood transfusions for GI hemorrhage. Other than that, she underwent several hospitalizations: 48 years ago for normal childbirth; in 1980 for Gastrointestinal hemorrhage; in 1995 for chest pain; in 1994 for the last mammogram; and in 1997 for Flexible Sigmoidoscopy.
Health Status, Perceived Barriers, and Support:
This patient has a record of congenital heart failure, risk factors of the coronary artery disease in hypertension, as well as the post-menopausal state having substernal pains of the chest.
Chief Complaint (CC):
This is the third time Ms. Julie is being admitted at the CPMC. She has had a long account of hypertension with a CC of a “toothache-like” pain in the chest for a 12 – hour’s duration.
Historical Account of Present Illness (HPI):
Ms. Julie has had a long tradition of hypertension, which was controlled previously on diuretic therapy. She had a first admission at CPMC in 1995 when she was complaining of the intermittent midsternal pain of the chest. At that time, her electrocardiogram showed first-degree atrioventricular block, while the X-ray showed a placid pulmonary congestion having cardiomegaly. However, she got discharged after briefly staying on enalapril, lasix, and digoxin regimens for her congestive failure of the heart.
She has been well until the night before this last admission. While she was sitting watching television, she noted an onset of pain beneath her breastbone. She took antacids and fell asleep. The pain then came back with amplified severity in the morning, after which her aunt rushed her to the hospital. This time, her electrocardiogram illustrated sinus tachycardia of 110, having ST altitude in I, V4-V6, AVL and infrequent ventricular convulsive contraction. Immediately, she received a thrombolytic therapy, as well as cardiac treatments.
Family and/or Social History (PFSH):
Ms. Julie’s mother died when she was 36 as a result of kidney failure. Her father, on the other hand, was accidentally killed in a car crash, when he was 41 years old. Besides, one of her sisters died during childbirth. As a result, she was raised up by her aunt. She has no known history of diabetes, cancer, or hypertension in the family.
Focused Review of Systems (ROS):
She has a stable weight of 160 lbs and a height of 5’8” with a good energy level. She has no complaints of headaches. She also puts on reading glasses but has no eye pains. However, for many years she has had hearing loss, thus, she now wears a hearing aid. In 1980 when she was admitted, endoscopy showed the presence of gastritis, which was presumed to have been caused by intake of ibuprofen. Several months later, she was examined with mild jaundice and lofty enzymes of the liver. It was noted that she had hepatitis B, which she got from the blood transfusions.
In conclusion, the interview with Ms. Julie was successful; however, her age and spiritual values were quite a challenge. With her age, it was difficult for her to remember some of her pasts making it hard to get some health facts from her. Other than that, I suspect her spiritual values made her deny some aspects such as cigarette smoking for the cause of her illness. However, it is proper that this patient continues with aspirin, nasal oxygen, nitrates and beta blockers. Other than that, she should continue with the ACE inhibitor therapy and monitor the pressure of the blood.