NURSING HEALTH HISTORY

I. Patient’s Data

Name : Mr. E.S.

Age : 79 y/o
Date of Admission : April 12, 2011
Diagnosis : Bilateral subdural hematoma r/t fall

Surgeries : Burr holes

Date of Surgery : April 13, 2011

Allergies : no known allergies

II. Past medical history

Past diagnosed illnesses: high cholesterol and Hypertension
Hospitalizations & operations: patient stated that he was never been hospitalized but went to his
doctor’s clinic couple of times for a routine blood test and check-ups for his cholesterol.
Medications prior to admission: ASA, Lipitor, enalapril/ atenolol.

Lifestyle
The patient has an active lifestyle. He gets up from bed as early as 5am to go for jogging or
cycling. He goes to gym 3-4 times a week and sometimes, he joins his wife’s aerobics class.
Most of the time he’s the one who cooks for himself and his wife. He’s fond of vegetables
and seldom eat meat products. He doesn’t smoke cigarette and drinks alcohol occasionally.
He sleeps 7-8 hours/ day and doesn’t have difficulty in sleeping. He has a housekeeper who
visits once a week to do household chores.

Psychosocial Data
The patient is a retired dentist and lives with her wife in a four storey house at Montreal.
He has 2 children and 5 grandchildren. The couple lives nearby their children’s houses and visits
each other regularly. The patient has lots of friends from work and neighbourhood whom he spends
time with occasionally.
He frequently asks for his Vital signs and he monitors his medication being given to him. He
is very much aware of his present condition and is concern if he can go back to his active lifestyle
and his concerns are well answered by his Physio and occupational therapist. He is very compliant
and participative in all aspect of care.

III. History of Present Illness

Patient stated that last February 2011, it was early in the morning, he was wearing his PJ`s
and a pair of socks and he get out of bed to turn the hallway light on which is situated a step away
from the stairs when he accidentally slipped for 6-7 flight of stairs in rolling motion with his head
down. He yelled for help and fortunately, his wife was at the house preparing to go to work. His
wife, retired and working part time anesthesiologist called 911. He was in a lot of pain in the head
due to trauma and felt really dizzy but never loses consciousness the whole time. He was brought to
Jewish General Hospital for CT scan and his doctor said there was a presence of inflammation but
only due to trauma and his brain are normal and no injury. He was given pain medications and cold
compress and was sent home the day after. He felt relieved but not his wife, due to her nature of
work, she decided to schedule his husband for a MRI in St. Mary’s Hospital and the soonest is on
April 12, 2 months after the accident. Meanwhile, pt. tried go back to his old active lifestyle but
experienced doing so with difficulty. He used to love cycling, hiking, travelling out of town and
country, he went to the gym 3-4 times a week and swimming, too but not anymore after the
accident. He was having on and off dizziness, always out of balance and blurring of vision. He
changed from active to sedentary lifestyle. April 12, he and his wife went St. Mary’s for MRI and
found the bilateral Subdural Hematoma. He was transferred immediately to MGH for an operation.

IV. Medications related to present illness

Name of medication Classification

1. Atenolol Beta blockers
2. Colace sodium Emollient Laxatives
3. Cefazolin IV Antiinfective
4. Tylenol Acetaminophen
5. Gravol Antiemetics
6. Phenytoin cap 400mg po daily 8h00 anticonvulsant