WRITE – UP HEALTH HISTORY

Date: 11/3/14 Examiner: lk

I. BIOGRAPHICAL DATA
Name: HV Phone: (631) 394-8725
Address: 255 sycamore avenue Ronkonkoma NY 11779
Birth date: November 2, 1996 Birthplace: St Catherine’s Long Island NY
Age: 18 Gender: Female Marital Status: Single Occupation: student
Race/Ethnic Origin: Caucasian / Puerto Rican Employer: private contractor

2. Source and Reliability: Patient herself, who seems reliable 3. Reason for Seeking Care: Pt states "Cough and congestion" 4. Present Health of History of Present Illness: Patient reports a wet cough for the last week along with congestion in the nose and sinuses. No pain but very uncomfortable especially during nights. Pt states “I went through a whole box of tissues last night”. The first symptoms were a sore throat which started at around midnight last week after work on 10/15/14. The following morning, her nose was stuffy and felt congested all throughout her head. These symptoms have been constant for the last week and have not resolved yet. Patient states her mucous is yellow and she has a lot of phlegm in her esophagus. Some things that have helped are vicks vaporub, sleep, tea, and a lot of water. Patient is not taking any medication for her symptoms because she wants her body to heal itself. She also states “I usually get sick like this, when the weather starts to change and winter is approaching”.

5. Past Health
Describe General Health: Reports being 125 pounds and feeling energetic and healthy
Childhood Illnesses: Reports had pertussis-cough, and impetigo
Accidents or Injuries: Reports fractured right foot at age 15, 3rd degree tear in left ACL at age 16 ; fractured mandible & loss of teeth at age 16.
Serious or Chronic Illnesses: Denies
Hospitalizations: Reports being hospitalized for a torn ACL at St Catherine’s Hospital
Operations: Arthroscopic Knee Surgery for torn ACL (age 16) ; Tonsillectomy- removal of tonsils (age 15) ; Both at St Catherine’s Hospital

Obstetric Hx: Gravida n/a Term (# Term Pregnancies) n/a Preterm (# preterm pregnancies) n/a
Ab/Incomplete (#Abortions/Miscarriages) n/a Children Living: Pt. denies.
Course of Pregnancy: n/a

Immunizations: Reports MMR, Influenza, Tetanus, PPD (Tuberculosis)
Reports Last Examination date 8/23/14

Allergies: penicillin, shellfish Reaction: hives/ fever, anaphylaxis Current Medications: Reports taking Loestrin 24Fe 1mg p.o qd ; Multivitamin 1tab p.o qd ; Iron(Fe) 1tab p.o qd

6. Family History – Specific
Heart Disease: Maternal Grandfather Allergies: Penicillin (Mother/Sister)
High Blood Pressure: Mother& Father Asthma: Denies
Stroke: Reports Denies Obesity: Father
Diabetes: Paternal Grandfather Alcoholism or drug addiction: Father (alcoholism)
Blood Disorders: Denies Mental Illness: Denies
Breast/Ovarian Cancer: Maternal Grandmother Suicide: Denies
Cancer: Denies Seizure Disorder: Denies
Sickle Cell: Denies Kidney Disease: Denies
Arthritis: Mother (hands) Tuberculosis: Denies

Construct Genogram Below

7. Review of Systems (Circle both past health problems that have been resolved and current problems including date of onset.)

General Overall Health State: Reports present weight loss of 10 pounds, in the last 3 months, by exercising and diet change. Denies fatigue, weakness or malaise, fever, chills, sweats or night sweats.

Skin: Denies history of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole,