Interview and the Health History
February 5, 2016 Time: 0815
Identifying Information
Ms. C. F. is a pleasant, oriented, 72 year old, widowed female. She is a retired housekeeper residing in Michie, Tennessee. She presents to the clinic today with complaints of an itchy rash under her right axilla that is accompanied by severe pain that radiates toward her right scapula. She states her right ear is also aching.
Source and Reliability
Self-referred. Deemed reliable. Says she came to clinic due to severe discomfort.
Chief Complaint
“This rash started on Wednesday, and has gotten much worse. It is oozing now. It’s been itchy and it hurts so bad. I just want to cry. I’ve never had anything like this! My ear has still been bothering me a …show more content…
C. F. reports having chicken pox as a child.
Adult Illnesses. Sinus infection x 1-2 yearly. Medical: GERD, hypertension
Surgical: Partial hysterectomy in 2001
Psychiatric: Oriented to person, place, time, and situation. Calm, pleasant. Affect appropriate.
Health Maintenance. Immunizations: Ms. F. states she is unsure what immunizations she had when, but knows she was vaccinated against Smallpox due to the scar on her left upper arm. Says, “I guess I got MMR vaccines and DTPs, but I’m just not sure when.” Has not received Zovirax vaccine. Did take flu and pneumonia vaccines last fall.
Screenings: Colorectal screening completed at age 70. States surgeon removed two small polyps that were benign. Opts no longer for Pap smear due to age 70. Had mammogram last year in July. No findings. Denies any concerns about STIs or HIV. Glucose and cholesterol labs done yearly at check up, blood pressure controlled with meds. Monitored per regular provider, Dr. S., in Adamsville, Tn.
Family History: Father had a history of HTN. Died of MI at age 82. Mother died of breast cancer at age 69. Ms. F. has one sister who has HTN and hyperlipidemia.
Current Medications
A & D ointment used BID x 3 days on Wednesday, Thursday, and
February 5, 2016 Time: 0815
Identifying Information
Ms. C. F. is a pleasant, oriented, 72 year old, widowed female. She is a retired housekeeper residing in Michie, Tennessee. She presents to the clinic today with complaints of an itchy rash under her right axilla that is accompanied by severe pain that radiates toward her right scapula. She states her right ear is also aching.
Source and Reliability
Self-referred. Deemed reliable. Says she came to clinic due to severe discomfort.
Chief Complaint
“This rash started on Wednesday, and has gotten much worse. It is oozing now. It’s been itchy and it hurts so bad. I just want to cry. I’ve never had anything like this! My ear has still been bothering me a …show more content…
C. F. reports having chicken pox as a child.
Adult Illnesses. Sinus infection x 1-2 yearly. Medical: GERD, hypertension
Surgical: Partial hysterectomy in 2001
Psychiatric: Oriented to person, place, time, and situation. Calm, pleasant. Affect appropriate.
Health Maintenance. Immunizations: Ms. F. states she is unsure what immunizations she had when, but knows she was vaccinated against Smallpox due to the scar on her left upper arm. Says, “I guess I got MMR vaccines and DTPs, but I’m just not sure when.” Has not received Zovirax vaccine. Did take flu and pneumonia vaccines last fall.
Screenings: Colorectal screening completed at age 70. States surgeon removed two small polyps that were benign. Opts no longer for Pap smear due to age 70. Had mammogram last year in July. No findings. Denies any concerns about STIs or HIV. Glucose and cholesterol labs done yearly at check up, blood pressure controlled with meds. Monitored per regular provider, Dr. S., in Adamsville, Tn.
Family History: Father had a history of HTN. Died of MI at age 82. Mother died of breast cancer at age 69. Ms. F. has one sister who has HTN and hyperlipidemia.
Current Medications
A & D ointment used BID x 3 days on Wednesday, Thursday, and