Nursing Health History Essay

2766 Words Nov 6th, 2013 12 Pages
Nursing Health History
1. Biographic Data A. Patient/Client Initials * K.E. B. Phone Number * 281-835-4377 C. Address * Missouri City, Texas D. Birthdate * October 26,1935 E. Age * 74 y/o F. Sex * Female G. Birthplace * India H. Marital Status * Widowed I. Race/Ethnic Origin * Asian Indian J. Occupation * House Wife K. Employer * N/A L. Financial Status * Her income comes from Social Security. Currently has Medicare as her health insurance. She lives with her son, allowing her to be able to support her lifestyle and health concerns. M. Source and Reliability of information * Client herself, who seems reliable.
II. Reason for Seeking
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There were no serious or chronic illnesses reported. There was also no past accidents or injuries: However, she did report past operations and hospitalizations. First one was in March 1984, client had Thyroidectomy. Second one was December 1984 when she had a Hysterectomy. Lastly, in 2002 and 2006 client had cataract removal from both of her eyes as an out patient surgery. 3. Last Examination
- March 23, 2010 was her last colonoscopy. June 11, 2010 was her last mammography August 24, 2010 was her last tonometry. 4. Obstetric Status
- Patient has had three full term children. Each newborn was health upon delivery. 5. Immunizations
- Client said she had some immunization in India. She does not remember what they were or what they were for. She received Flu vaccine last year. 6. Current Medications
- Atenolol 100mg p o daily for blood pressure. Levothyroxine 175 mg p o daily for Thyroid. Simvastatin 20 mg p o at bedtime for Cholesterol.
- Client has Medicare that covers her costs for medications. Clients also stated that the medications do work and she does not feel side effects from them. She only has three medications and takes them religiously.
IV. Family Health * Her husband died in 1985 from a heart attack. She has two boys and one girl; they are married and have children of their own. All her children live in USA and are in good health. One of her children does have cholesterol and another one of her kids does have

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