Health History and Assessment

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NUR 109
Section One: Biographical Data:
Name: S62F
City oI Residence: Craig, CO
Age: 62
Birth Date: 10/10/1949
Birth Place: Ness City, KS
Gender: Female
Marital Status: Divorced
Ethnic Origin: Italian/German
Occupation: (past) 911 Dispatch
The inIormation is being Iurnished by the patient.
Section Two: Reasons Ior seeking care (or ChieI Complaint)
'I had these lumps in my stomach area and they were very painIul.
Section Three: Present health or history oI present illness:
Location: 'In my stomach
Character or quality: 'Sharp pain, especially when touched

"uantity or severity: 'Once the lumps got big it hurt all the time. I couldn`t even wear my
normal clothes; I had to buy big sweatpants so I could be comIortable.
Timing, onset, duration, Irequency: 'I saw the lumps about six months ago, they were the size oI
small lemons. I didn`t think too much about it because I had gained some weight, but then they
started growing and getting lower. Once they hit my stomach area they hurt pretty much all the
time because my pants hit them.
Setting: 'I Iirst noticed them when I was taking a shower.
Aggravating or relieving Iactors: 'Well, like I said, having clothes touch them hurt. When
nothing was touching them it really didn`t hurt much, until they started growing, then they hurt
real bad.
Associated Iactors: The primary symptom is not associated with any other symptom.
Patient`s perception - how it aIIects daily activities: 'I wasn`t sleeping well, I kept rolling in my
sleep onto my stomach and it would hurt. I couldn`t wear my clothes anymore either because
they weren`t Iitting right anymore.
Section Four: Past Health History:
Childhood illnesses: 'I had chickenpox when I was Iour, measles at age Iive, and I believe I had
mumps not too soon right aIter that, maybe when I was six or seven.
Accidents or injuries: 'When I was eight we went on a Iamily vacation to a beach in Florida. I
got caught in an undertow and drowned. My daddy, who was cop, did cpr on me and brought me
back to liIe. He was my hero.

Chronic or serious illnesses: 'I`ve had migraine headaches oII and on Ior about 10 years. I
don`t have to take medicine Ior them because I have this woman Iriend who can cure me with
her hands. She just touches my head with her hands and my headache is gone. She has a giIt.
I`ve also had lymphoma cancer and uterine and cervical cancer. I was cured Irom a serum that I
had gotten Irom a doctor in Mexico.
Operations: Pt stated she had no operations even though she had breast implants (in her
abdomen) and scars Irom liposuction.
Obstetric history: 'I have Iive children, Iour boys and one girl. I`ve never had a miscarriage.
Immunizations: 'I know I got vaccinations as a child, but I don`t remember what they were
called.
Last examination date: 'Well, I had an examination when I came here, does that count?
Allergies: 'I`m allergic to iodine..
Section Five: Current Medications:
Risperdal 1mg hs, Klonopin 4mg hs, nicotine patch 14mg q24h. PRN medications: Xanax
- 2mg PRN TID, Tylenol 650 mg PRN "4H
'The risperdal and klonopin are Ior my schizophrenia. I really don`t remember when I
started taking them, it`s been a while. They keep me grounded and stop me Irom having panic
attacks. When I`m not taking them I have panic attacks real bad. I Ieel okay when I take them.
The nicotine patch is just because the nurses don`t want me to smoke. As soon as I go home I`m

not using it anymore. I like to have my one cigar a day. I`ve been smoking cigars Ior years and
it hasn`t hurt me yet.
Section Six: Family History:
Grandmother died age 87, Father died age 76, Mother died age 89, and Brother died age 9
Heart Disease: Grandmother, Mother
Diabetes: Grandmother, Sister
Stroke: Father
Leukemia: Brother
Mental Illness: Pt stated that her mother, grandmother, and sister were all diagnosed with
schizophrenia.
Section Seven: ROS:
General overall state oI health: 'Ever since the doctor took those lumps out oI my stomach I`ve
had horrible back pains. I`m thinking that maybe I`m getting lumps in my back also. I really
need to go back to that doctor in Mexico. He`s the only one that can cure my cancer.
Skin: 'I`ve always had beautiIul skin, it`s my heritage.
Head, Headaches, dizziness, and injuries: 'I told you I get migraines, but my Iriend keeps them
under control.
Eyes: 'I wear glasses, but it`s just Ior seeing up close.

Nose and sinuses: 'I`ve never had allergies.

Mouth and throat: 'No problems.
Neck: 'No problems.
Breast pain: 'My breasts are Iine, huge, but Iine.
Axilla, Respiratory system, Cardiovascular system, Peripheral vascular system: 'No problems.
Gastrointestinal system: 'Since the operation I haven`t been able to poop normal. When I did
poop it was just a tiny bit. My stomach is so big since the surgery; I can`t wait until the swelling
goes down. I Ieel so Iat.
Urinary system: 'I`ve had to go to the bathroom at night and I Iorget where I am and make a
mess on the Iloor. During the day I`m okay, I don`t make any messes.
Male/Female genital system: 'No problems there.
Sexual Health: 'That`s private inIormation, I`d rather not discuss it with you.
Musculoskeletal system: 'No problems there.
Neurological, Hematological and Endocrine system: 'No problems.
Section Eight: Functional assessment, including activities oI daily living:
SelI-esteem: 'I like myselI.
Activity/rest: 'BeIore the surgery I was really active. I walked my dog every day and visited
with my neighbors on a weekly basis.

Nutrition: 'I don`t Iollow a diet. I can still eat whatever I like, but not as much oI course.
Interpersonal relationships: 'I don`t have a man in my liIe right now and I`m not looking.
Spiritual resources: 'I don`t go to church here, but when I move back to Denver I`ll be going
with my grandkids. They love going to church with their grandma.
Coping and stress management: 'When I`m really stressed, I like to go Ior a walk. I put on my
headphones and listen to Waylon Jennings. He always makes me smile.
Personal Habits: 'I always shower every day, whether I need it or not. My momma always told
me that every day I should put on a clean pair oI underwear because you never know when you
might get in an accident.
Alcohol use and Street drugs: 'I`ve never drank, ever and I`ve never used drugs.
Environment/hazards/intimate partner violence: 'I live in a saIe neighborhood; we all know
each other and help each other out.
Section Nine: Physical Examination:
General Survey: Patient is a 62 year old woman who came in Ior removal oI Ioreign masses in
her abdomen. She was diagnosed with schizophrenia many years ago, and according to her this
disease runs in the Iamily. She seemed very lucid throughout the interview, but when we were
discussing how the masses appeared in her abdomen, she stated 'the lumps started out small, like
little lemons, and then grew over six months time. She also stated that she had never had breast
augmentation, which I could not conIirm or deny since I did not Iind any scarring around the
breast which would coincide with breast surgery. The patient did have bilateral 2 cm circular

incisions in the Ilium area. The doctor conIirmed that the incisions were Irom liposuction, which
the patient also denied having. Most oI the time the patient appeared lucid, the only time she
was conIused was upon wakening one morning, she thought she was at home and she needed to
get ready to go riding with her Iriends. When she realized that she was still in the hospital, she
apologized proIusely Ior thinking she was going Ior a ride. I stated to her that it was a common
mistake some patients make upon waking Irom the hospital; patients sometimes think that they
are at home. My statement eased her mind. Other than the one early morning episode, patient
was AAO x3, with clear speech. Patient ambulated with assisted device (walker).
Height: 5`8 Resp: 20 BMI: 28 (pre-obese)
Weight: 183 lbs Temp: 98.3
BP: 150/75 Sp02: 94 on room air
Pulse: 84 Pain: 4/10(post-op day 1)
Skin: Normal, pink and warm. When doing the initial head to toe assessment noticed the two 2
cm circular wounds in the Ilium area. Pt was unaware oI how they came about. I spoke with her
doctor and he stated that it was Irom liposuction. All oI her skin was hydrated, no Ilaky, dry
areas. The wound area Irom her surgery was clean, and Iree Irom inIection. Pt had bilateral
wounds; 5 cm Irom the umbilicus, each wound was approximately 6.35 cm in length and 2 cm in
height. Pt had JP drains in each oI the wounds.
Head: AAO x4 (time, person, place and selI). Hair was grey/blonde, to be expected with age.
Hair was med to thick in texture, no hair loss noticed. Facial Ieatures, bilaterally symmetrical.
Scalp clean, dry, healthy, no lesions. HEENT: WNL

Eyes: PERRLA: WNL. Patient wears prescription glasses Ior hyperopia.

Nose: Patency oI the nostrils is WNL.
Mouth: Patient wears Iull set oI dentures, except at bedtime. Patient perIorms denture hygiene
on own. No lesions in mouth area or on tongue. Mucous membranes are pink and moist.
Neck: WNL. Throat and neck palpated, no areas oI tenderness.
Spine and back: WNL. Palpated spine, no tenderness. Patient stated 'since the surgery I`m
having lower back pain. It hurts when I`m lying down on my back. Patient stated that on a
scale oI 1 to 10, her back pain was 5. Patient receives Tylenol 650 mg Ior pain.
Thorax and lungs: Clear breath sounds. Patient diligently uses spirometer 1x every hour to help
with post surgery anesthesia eIIects.
Breasts: Palpated breasts, WNL. No lumps or lesions.
Heart: WNL, apical HR: strong
Abdomen: Did not palpate abdomen due to bilateral surgical wounds. Auscultated x4, miminal
bowel sounds due to post surgery. Patient stated she had only 1bm since surgery date. Spoke
with Nurse, she conIerred with Doctor and ordered Colace 50 mg and also stated that I should
get her some prune juice with butter.
Extremities: WNL. Hands and Ieet are pink, warm, and dry. Cap reIill normal.
Musculoskeletal: Bilateral strength in both arms and legs are equal and strong. Patient was able
to demonstrate ROM Ior upper extremities, and PROM Ior lower extremities due to surgery.

Neurological: Mental status during interview was AAO x3. Tested cranial nerves III, IV, and
VI, PERRLA. Tested cranial nerve V, patient is able to perIorm WNL. Tested cranial nerve
VII, patient is able to perIorm WNL, tested cranial nerve XI, patient is WNL.
Genitalia: Inspected external genitalia, hair distribution is appropriate Ior age, no pediculosis
pubis. Skin oI the mons pubis and labia is intact with no lesions or discharge.
Section Ten: Abbreviated Summary:
Due to my patients mental status, the background inIormation on the HHA may be
exaggerated, but the inIormation on the assessment in correct. I Iound the patient to be very
likeable, and the only time I could ascertain that she was schizophrenic was when she stated that
she did not have breast augmentation, or liposuction, when clearly she did due to the surgical
wounds. I personally did not Iind the scars Ior the breast procedure, but I conIirmed with her
doctor that she did have the procedure done. She was a very easy patient to take care oI. She
Iollowed my adv ice on using the spirometer to keep her lungs strong, and also to keep
ambulating to increase her strength and also move her bowels. It was a pleasure taking care oI
her Ior the two days I was in clinicals.