HEALTH HISTORY FORM

SITUATION

1.1 Place and Time:-City: Chiclayo- Day:-Time: 8:30 a.m..- Hospital: Almanzor Aginaga Asenjo National Hospital-Service: Emergency

1.2 Presentation of the Patient:- Sex:- Age: - Sign (s) outstanding (s):

1.3 Ectoscopia:a. State of gravity apparent: (Regular)b. Apparent age: (compatible with current age)c. Sign (s) outstanding (s):

1.4 HISTORY

AFFILIATIONa) Name: b) Age: c) Sex: d) Breed:e) Marital status: f) Occupation: g) Degree of higher education:h) Religion: i) Birthplace: j) Hometown:k) Join Date: DATABASEHistory of present illnessDisease Time: Major Signs: Home Form: (Insidious) Course: (Stationary)

Chronological Story:Biological Functions:Appetite: Thirst: Urine:Depositions: Sleep:

PERSONAL HISTORY

A. NonpathologicalBirth: Physical Development: Psychic Development: Socioeconomic:Previous Residences:.Obstetric and gynecological history:FUR: Habits and customs:Smoking: Alcohol:

B.PatolgicosPrevious illnesses:Contact TBC: NegateAccidents and sequelae: (Negate)Surgical procedures: (Denies)Regular medication or transfusions: (Deny use of oral contraceptives and transfusion)Allergies to medications:

D. FAMILYMother: (No history of importance)Father: ( No history of importance)

REVIEW OF SYSTEMS AND DEVICES ANAMNESTIC:GENERAL: (Fever, chills, sweats, weight changes, weakness, fatigue, heat/cold intolerance, bleeding, radiation)SKIN, HAIR, NAILS: Rashes, lumps, sores, itching, color or texture changes, bruising, abnormal growthsHEAD: (Headaches, injury, dizziness, syncope, LOC, stroke)EYES: (Vision/correction, blurring, diplopia, eye meds, trauma, redness, pain, glaucoma, cataracts)EARS: (Hearing/loss, pain, discharge, infection, tinnitus, vertigo/"dizziness")NOSE: (no epistaxis or obstruction)

MOUTH & THROAT: (Hoarseness, sore throats, gum problems, tooth abcess, dental care, sore tongue, taste)NECK: ( Lumps, "swollen glands," goiter, pain/stiffness)LYMPH NODES: (Enlargement, tenderness)RESPIRATORY: (Pain, dyspnea, SOB, cyanosis, wheezing, cough, sputum (color & quantity), asthma, bronchitis, emphysema, pneumonia, TB/BCG)CARDIOVASCULAR: ( Chest pain/distress, palpitations, SOB, dyspnea, orthopnea (pillows needed), paroxysmal nocturnal dyspnea, rheumatic fever, murmur, exercise tolerance, hypertension, edema, leg pains/edema/coolness/hair loss, varicose veins, thrombosis, ulcers)GASTROINTESTINAL: ( Appetite, digestion intolerance, heartburn, hematomesis, bowel irregularity, stool appearance, flatulence, hemorrhoids, jaundice, ulcer, gallstones, abdominal enlargement)ENDOCRINE: (Thyroid enlargement/tenderness, heat/cold intolerance, unexplained weight change, diabetes)MALE REPRODUCTIVE: ( Puberty onset, erections, testicular pain or masses, hernias, lesions/discharges, , sexual activity, , infertility, prostate)FEMALE REPRODUCTIVE: (Menses Menarche, regularity, duration & amt. of flow, dysmenorrhea, sexual activity, contraception, fertility, menopause, discharge, itching)Gravida/para: (preg. duration, antepartum problems) BREAST: (Pain, tenderness, discharge, lumps, galactorrhea)GENITOURINARY: (Dysuria, pain, frequency, urgency, nocturia, hematuria, stress incontinence)MUSCULOSKELETAL: (Joint stiffness, pain, motion restriction, weakness, paresthesias, cramps, deformities, back problems)HEMATOLOGIC: (Anemia, lymph swelling, bruising/petechiae, fatigue, blood , transfusion, radiation )NEUROLOGIC: (CNS disease, syncope, blackouts, dizziness, numbness, tingling, seizures, weakness/paralysis, tremors coordination, memory, cognition, headaches, head injury)

PHYSICAL EXAM

1. Vital Signs: Temperature: Pulse: Respiration: Blood pressure:

2. General appearance: (slightly obese, elderly black woman sitting up in bed)

3. Regional

Skull: (normocefalo)Eyes: (extraocular motions full, gross visual fields full to confrontation, conjunctiva clear. non-icteric, pulpils equal round and reactive to light andpossible presence of cataracts).Ears: (Hearing very poor bilaterally. Tympanic membrane landmarks well visualized).Nose: (No discharge, no obstruction, septum not deviated)Mouth: (Uvula moves up in midline).4. Neck: (jugular venous pressure 8cm, thyroid not palpable. No masses).5. Nodes: (No adenopathy)6. Chest: (no masses or discharges. Lungs: bibasilar . No dullness to percussion. Diaphragm moves well with respiration. No rhonchi, wheezes or rubs).7. Heart: (PMI at the 6th ICS, 1 cm lateral to MCL. No heaves or thrills. Regular rhythm) 8. Spine: (mobile, nontender, no costovertebral tenderness)9. Abdomen: (soft, flat, bowel sounds present, no bruits. Nontender to palpation. Liver edge, spleen, kidney not felt. No masses. Liver span 10cm by percussion.)10. Extremities: (skin warm and smooth except for chronic venous stasis changes in both legs. 1+ edema to the knees, non-pitting and very tender to palpation. No clubbing nor cyanosis.)11.Neurological: (Awake, alert and fully oriented. Cranial nerves III-XII intact except for decreased hearing. Motor: Strength not tested, patient moves all extremities; no Babinski sign).12. Pelvic: (deferred until patient more stable)13. Rectal: (Prominent external hemorrhoids. No masses felt).

Labs Hgb 12.0 Hct 38.0 Glu 102 BUN 9 Creat 0.8

Impression1. Hypertension2. Dysuria (bacteria in urine with pyuria)

Plan1.Continue treatment.2. Obtain echocardiogram .3. Continue monitor blood pressure.