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Health History Paper


Biographical data:

Interview date/time: 2/3/2012, 8 a.m.

Examiner: student nurse

Client: J.P.

Address: 123 Penny Lane, Anywhere, NY 12345

Birth date: 10/16/1975

Age: 36

Gender: Male

Birthplace: Anywhere, NY

Marital status: Married

Employer: East House Corporation

Occupation: Mental Health Counselor

Race/ethnicity: Caucasian

Identifying data: JP is a 36-year-old, married, Caucasian male, a willing participant in interview, appearing stated age; resides at 123 Penny Lane, Anywhere, NY; born 10/16/1975; mental health counselor

Source of history: Contributor of data was client; alert and oriented to person, place, and time; engaged in interview, reliable

Reason for seeking care: Client presents with cough with sputum production, sharp chest pain on inspiration, shortness of breath, body aches and fever, “my fever was 103.2 before coming in”

History of present illness: Thirty-six-year-old male presents to office complaining of cough pain in chest, body aches and fever, states pains and fever started 6 days ago. Rates pain as 6 to 10 out of 10, continuous. Patient states he took his own temperature with an oral thermometer with temps ranging from 101.9 to 103.2.

Past medical history:

• Fibromyalgia

• Epilepsy

• Pericarditis

• Heart Burn

Past surgical history: Denies any past surgeries

Childhood illnesses:

• Chickenpox

Accidents or injuries:

• Car accident, 1992

History of hospitalizations: • Full cardiac workup, 2004 • Monitored 1994, due to black outs

Immunizations: Up-to-date, including PPD and influenza, Hep B series 2011

Examinations/screening/diagnostic tests: (a) client indicates seeing PCP, cardiologist every six months, neurologist, and rheumatologist on yearly basis; however, client is aware of need to schedule appointments for 2011 (b) routine eye exam, 2011 (c) routine dental checkups every six months, teeth in good repair, last dental examination 2011 (d) EKG, 2012

Actual dates of exams are unknown by client

Allergies: No known drug allergies

Current medications:

• Savella 50 mg, b.i.d.

• Nitroglycerin dissolvable pill, dosage unknown

• Aspirin 325 mg every day

Family history:

• Heart disease: denies

• Hypertension: denies

• Stroke: denies

• Diabetes: denies

• Blood disorders: denies

• Breast/ovarian cancer: aunt, breast cancer

• Cancer (other): maternal grandmother, lung cancer

• Sickle cell: denies

• Arthritis: maternal grandmother

• Allergies: self, brother

• Asthma: denies

• Obesity: denies

• Alcoholism/drug addiction: 10 uncles both maternal and paternal, 2 aunt both maternal and paternal

• Mental illness: aunt

• Neurologic: self, aunt

• Seizure disorder: self, aunt

• Kidney disease: denies

• Tuberculosis: aunt

• Vascular disease: denies

• Infectious disease: denies

Review of systems:

• General overall health: weight gain/loss no greater than 10 pounds over 12-month period of time; fatigue/weakness times six months; fever currently present; denies chills, sweats, night sweats

• Skin: denies pigment/color change, change in moles, excessive dryness or moisture, denies; excessive bruising, rash, or lesion

• Hair: male patterned baldness; denies change in texture

• Nails: denies change in shape, color, or brittleness

• Head: denies vertigo, frequent or severe headache, head injury

• Eyes: decreased acuity, wears prescription glasses; denies eye pain, diplopia,

• watering or discharge, redness or swelling, glaucoma, macular degeneration, retinopathy, floaters, ocular migraines

• Ears: denies vertigo, earaches, infections, discharge, tinnitus, hearing loss

• Nose and sinuses: sinus pain; denies unusually frequent or severe cold, nasal obstruction, nosebleeds, allergies, hay fever, change in sense of smell

• Mouth and throat: daily care of oral cavity, brushes b.i.d.; routine six-month checkup; denies mouth pain, sore throat, bleeding gums, toothache, dentures, mouth lesions, tongue lesions, dysphagia, hoarseness, vocal change, tonsillectomy/adenoidectomy, altered taste

• Neck: denies swollen or tender glands, enlarged or tender lymph nodes, limitation of movement or stiffness, goiter

• Axilla: denies tenderness, lumps, or swelling, rash

• Respiratory: shortness of breath; coughing with sputum production; denies asthma, emphysema, bronchitis, pneumonia, tuberculosis, chest pain with breathing, wheezing or noisy breathing, hemoptysis, toxin or pollution exposure

• Cardiovascular: history of pericarditis; EKG 1/12; denies precordial or retrosternal pain, palpitations, cyanosis, orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, denies; murmur, coronary artery disease, anemia

• Peripheral vascular: denies varicose veins, lower extremities, coldness, numbness, or tingling, leg swelling, discoloration of hands or feet, claudication, thrombus, phlebitis, ulcers

• Gastrointestinal: flatulence; frequent heartburn with eating spicy foods; good appetite; constipation r/t current medications; denies nausea or vomiting, other abdominal pain, ulcer, liver, or gallbladder disease, jaundice, appendicitis, colitis, abdominal surgery, diarrhea, black tarry stool, rectal bleeding, hemorrhoids, use of laxatives

• Genitourinary: mild to moderate urinary frequency; nocturia; denies dysuria, polyuria, or oliguria, hesitancy or straining, kidney disease, kidney stones, urinary tract infections, flank, groin, suprapubic, or low back pain

• Sexual health: sex drive has been significantly decreased r/t medication, average of 3 times a year; denies any changes in erection or ejaculation, any STI’s

• Musculoskeletal: pain, stiffness in joints r/t fibromyalgia; pain, cramps in muscles r/t fibromyalgia; lower back pain r/t fibromyalgia, pain decreases with movement; denies gout, deformity, crepitus, ataxia, cramps, claudication

• Neurologic: history of petit mal seizures; fainting; blackouts; weakness; tic or tremor, paralysis, coordination problems, memory loss recent; denies stroke, numbness and tingling, depression, hallucinations

• Hematologic: denies easy bleeding or bruising, lymph node swelling, exposure to toxic or radiological agents, blood transfusions

• Endocrine: denies diabetes, diabetic symptoms (polyuria, polydipsia, polyphagia), thyroid disease, heat or cold intolerance, change in skin color or texture, excessive sweating, abnormal hair distribution, tremors, hormone therapy

Functional assessment:

• Self-esteem, self-concept: (a) client is a mental health counselor, married for 5 years with 4 children (b) indicates good general health, though acknowledges minor limitations related to fibromyalgia pain (c) very involved children’s extracurricular activities, i.e. softball coach, and wrestling mentor (d) high school diploma, currently attending Monroe Community College to obtain an associate’s degree

• Activity, exercise: (a) client is an avid hunter, (b) walks 1-2 miles a day on treadmill as recommended by PCP to prevent fibromyalgia pain, (c) client is active in church, and attends services weekly in addition to other religious holidays (d) independent with ADLs and IADLs

• Sleep/rest: client indicated not sleeping well at nighttime, r/t fibromyalgia pain, and nocturia

• Interpersonal relationships/resources: (a) client is married 5 years, father of four living children; children are all under the age of 18 and live within the home (b) client values the quality of his friends, and enjoys being with extended family often (c) client interacts with the sports community at daughter’s softball games and son’s wrestling tournaments (d) client travels to Maryland to see father once a year and also visit’s spouses family in Chicago, IL once a year as well

• Spiritual resources/values-beliefs: Christian faith, attends church weekly as well as holidays

• Coping, stress management, mental health: (a) as a mental health counselor, client has many resources, such as coworkers, EAP (employee assistance program), supervisors (b) gardening, woodworking, hiking (c) tries to live a stress-free life style, “I am father of 4 children, states “there is always something to be stressed about”

• Self-care behaviors: takes medications as directed; yearly physicals

• Financial status: able to pay bills and enjoy recreational activities, “could always use more money”

• Personal habits: (a) client admits to smoking at least ½ a pack a day, states “I started as a teenager, I do plan on quitting in the very near future” (b) client enjoys a beer on occasion, mostly on holidays when celebrating with family (c) client consumes six to seven cups of coffee per day; (d) denies any risky behavior, drug addiction, history of STI’s

• Environmental hazards: (a) client resides in a one-story ranch in rural area, safe neighborhood, all amenities available (b) client uses seat belt at all times when driving (c) use of cane is also indicated for stability purposes, both within the home and out in community; client refuses to use walker, despite daughter’s willingness to purchase (d) client wears lifesaving call button at all times, purchased by children in case of emergency

• Intimate partner violence: none, client is widowed and has not been involved in a relationship since death of husband; no history of domestic abuse during marriage

• Occupational health: (a) client states “working with the mentally ill there is always a risk, I have been assaulted on more than on occasion but it’s all a part of the job

• Nutrition/Elimination: client states “ I eat what his wife makes for dinner, which is usually a well-balanced diet, compromised of whole grains, vegetables, lean meats or fish, of course there is an occasion when traveling from sporting event that fast food is consumed, wife really pushes for a healthy diet”; eats dinner with the family at the dining table 95% of the time; able to perform 24-hour diet recall

• Health Perception: (a) client defines “health” as “not being in pain, living a productive lifestyle and not allowing fibromyalgia to take over his life” (b) client expects that fibromyalgia will one day take over his life taking away his abilities to function as a productive member of society, client states “I know so many people who have to quit work because of fibro, I don’t know what I’ll do if I have to quit my job because the pain is to severe" (c) goals are to quit smoking and live a healthier lifestyle for himself and his family.

Summary: 36-year-old, Caucasian male, cooperative and cognizant of his health history as well as factors that may limit his daily activities. Client is currently independent in ADLs and IADLs and demonstrates cognitive faculties, feels that his independence will diminish as the fibromyalgia progresses. Client acknowledges continuation of current extracurricular activities and has no concerns regarding social isolation. In addition, client is motivated in self-care and maintaining current health state, perceiving interpersonal relationships having a beneficial impact on her well being. An area of concern for the client is his anxiety related to being the not being a productive member of society and providing for his family. Referral to PCP for chest pain and sputum producing cough, along with referral for smoking cessation programs in his area in addition to educating client regarding group meetings at FARNY, Fibromyalgia Association of Rochester, NY, in conjunction with learning more coping strategies to assist with issues related to fibromyalgia. As noted on the website there are many different forms of therapy such as dance therapy, humor therapy, hydrotherapy. (FARNY, 2012)

There are also many different smoking cessation programs, client can become educated on the benefits of becoming a non-smoker and the risks involved if he continues. (State of New York , 2012)

• Nursing diagnoses:

1. Ineffective breathing pattern as evidence by shortness of breath

2. Body temperature, imbalanced, risk for as evidence by “103.2” temperature

3. Constipation, perceived

4. Readiness for enhanced self-care related to history of fibromyalgia

5. Readiness for enhanced Decision making related to choice to quit smoking

6. Readiness for enhanced community coping related to joining group for Fibromyalgia sufferers

7. Sexuality pattern, ineffective

8. Chronic pain related to pre-diagnosed medical conditions


Fibromayalgia Association of Rochester, NY . (2012, February 9). Retrieved from Fibromayalgia Association of Rochester NY:

Gail B. Ladwig, M. R. (2011). Nursing Diagnosis Handbook: An Evidence Based Guide to Planning Care, Ninth Edition. St. Louis: Mosby, Inc.,an affiliate of Elsevier Inc. .

Jarvis, C. (2012). Physical examination and health assessment (6rd ed.). St. Louis, MO: Saunders Co.

State of New York . (2012, Feb 15). New York State Quitters Hotline. Retrieved from New York State Quitter Hotline:

Taylor, C., Lillis, C., LeMone, P., Lynn, P. (2011). Fundamentals of nursing, the art and science of nursing care (7th ed.). 252(4). Philadelphia, PA: Lippincott, Williams & Wilkins

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