Comprehensive health history
Name: Ms. Johnson
Address: Block 15, Maiden Street California
Age: 64 years old Sex: F Citizenship: American Religion: Christian (Catholic)
Birthdate: August 16, 1954. Civil Status: Married Educ. Attainment: College Graduate
Birth Place: California
Occupation: House Wife
Health Insurance: Yes
Information obtained from: Patient
Chief Complaint: Ms. Johnson is a 64-year-old patient admitted one day ago due to a failed arteriovenous fistula on the left upper arm. The fistula was inserted one month ago, but after four cycles it failed.
History of Present Illness: Ms. Johnson was diagnosed with End Stage Renal Disease (ESRD) four months ago. A temporary catheter was inserted in the left internal jugular vein where she continued her dialysis for three months. One month ago, a permanent catheter was inserted at the left upper arm, but after four dialysis cycles, it failed. She was then admitted to the hospital for a checkup and possible re-fixing of the fistula.
Past Medical History: Ms. Johnson is a patient with a long history of hospitalization. She was first admitted in 1996 with a complaint of a severe headache and chest pain. After a medical examination and several tests, the patient was diagnosed with hypertension. The patient was discharged after a brief stay in the hospital and was started on antihypertensives. Enalapril, Lasix, and digoxin tablets were prescribed, and she has been on follow up with her cardiologist.
In 2012, the patient was admitted to this facility with a complaint of excessive sweating, edema, and headache. After a thorough review by the medical team, she was diagnosed with acute kidney disease. After medication and close monitoring, the patient’s condition improved. The kidney function tests showed standard kidney function and the patient was discharged on medication. She stayed in the hospital for three weeks. In 2015, the patient got admitted again with complaints of a headache, chest pain and difficulty in breathing. X-ray results showed mild pulmonary congestion with cardiomegaly. She stayed under monitoring and medication for two months before discharge. The patient has been on medication until September 2017 when she got hospitalized again. She presented with complaints of restlessness, difficulty in breathing, chest pain, parlor, and anuria. After X-ray and MRI, the patient was diagnosed with ESRD and started on dialysis immediately.
Family History: The patient was brought up by her parents. She is the second born in a family of two. Her mother died 32 years ago from kidney failure, and her father followed two years later with pneumonia. Her husband is alive. Ms. Johnson has two sons of age 38 and 32. There is a history of hypertension in the family because her grandmother died from the condition. There is no known history of diabetes or cancer.
Personal History: Both parents raised her in California where she went to school up to college level. She reports a proper development of milestones to include walking and talking. Her menses delayed up to the age of 16 years, but she experienced no problem after that. She stays at home most of the time and his two sons provide money for upkeep.
Socio-cultural History: She is a housewife and gets money for upkeep from his two sons. Ms. Johnson does not drink or smoke. She spends most of her time at home and goes to church often. Her diet is restricted because she is hypertensive and has kidney failure. No social groups or cultural practices relevant to patient hospitalization noted.
Review of Systems
HEENT: No complaints of headache change in vision, nose or ear problems.
Cardiovascular: Chest pain, heart murmurs and increased heart rate of 120b/m
Respiratory: No coughing or wheezing noted. Patient reports difficulty in breathing while in a prone position.
Gastrointestinal: No complaints of dysphagia, nausea or vomiting.
Genitourinary: Patient is on dialysis. There is no history of STIs.
Musculoskeletal: Complaint of lower back pain after a few hours of work. Pain usually relieved with Tylenol.
Neurological: no weakness, numbness or incoordination noted.
The interaction with Ms. Johnson was fairly good because I managed to obtain most of the history without assistance from the relatives. The environment for the exercise was quiet, spacious room with adequate lightening. The assessment was done at 1100 hrs shortly after administration of her medication. I approached the patient well starting with greetings and then initial part. She allowed me to take her history and then I proceeded. Her voice was not loud enough, so I kept on repeating some of the questions. I was forced to move closer to the patient for better hearing. All information required was obtained although the past medical history took much time. I had a challenge with time management because of the communication problem and detailed information about the patient. I would like to minimize the time span the next time another assessment is done.