Medical History Outline
September 24th, 2021 at 3:37 pm
Identification:
AKE is a 27 year old Haitian American female who is single and a Jehovah Witness. AKE address is 123 Westbury ave, Westbury NY 11321.
Informant: Patient themselves, reliable
Referral Source: Self
Primary Care Physician: Paul Orbon, DO on Stewart Ave, Garden City.
Chief Complaint:
Lower Back Pain x 1 week
Present Illness:
Ms. AKE is a 27 year old female with no significant past medical history who complains of persistent lower back pain for a week now. She says that the pain started out of nowhere and that the pain is five and a half out of ten. The patient states that the pain does not radiate but stops her from bending down. The patient has been taking tylenol 500mg and Advil 100mg and states that it helps for only 30 minutes and then the pain returns. She says that she has not lift anything heavy or had injury to her back to feel this pain.
Past Medical History:
Smoking x 6 yrs
No past Medical illness
No Childhood illness
Immunizations Up to date
Past Surgical History:
No Surgical History
Medications:
Multivitamins P.O. Once a Day
For daily health reasons.
Allergies:
Coconut- Anaphylaxis shock
Latex- Hives
Family History:
Father (deceased age 45) Stomach cancer
Mother (deceased age 58) Lung cancer x 2 metastasized to esophagus, DM
Maternal Grandmother (Deceased age 83) HTN, MI x 2, Hypercholesteremia
Sister (Living age 26) PCOS
Brother (Living age 30) Asthma
Social:
Habits- Alcohol- 1 glass of wine per dinner everyday x 3 years
Smoking Marijuana- everyday for 6 years
Travel: Recent travel to Jamaica.
Occupation history: Nurse Case Manager
Marital history: Single
Home Situation- Living with 1 sister and 1 dog (pomeranian)
Diet: Balanced but admits to eating fast food 3x per week.
Exercise: long walks x 1-2 days a week
Sleep Patterns: Admits that it is hard to fall asleep and only sleep for about 5 hours
Review Of Systems :
General– Lower Back pain, Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fevers, chills, or night sweats.
Skin, hair and nails- Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution
Head- Denies headache, vertigo, head trauma.
Eyes- Denies visual disturbance such as blurring, diplopia, fatigue with use of eyes, scotoma, or halos Denies lacrimation, photophobia, pruritus.
Ears- Denies deafness, pain, discharge, tinnitus, or use of hearing aids.
Nose/Sinuses- Denies discharge, epistaxis, obstruction.
Mouth and throat- Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, or use of dentures.
Neck- Denies localized swelling or lumps. Denies stiffness or decreased range of motion.
Breast- Denies lumps, nipple discharge, pain.
Pulmonary System- Denies SOB and DOE. Denues coughing, wheezing, hemoptysis, cyanosis, orthopnea, or PND.
Cardiovascular System-Denies chest pain, HTN, palpitations, irregular heart beat, syncope, and known heart murmur.
Gastrointestinal System- Denies loss of appetite, pyrosis, nausea and vomiting, dysphagia, flatulence, eracuations (belching, burping), abdominal pain, jaundice, change in bowel habits, hemorrhoids, constipation renal bleeding. Denies stool guaiac, colonoscopy, and sigmoidoscopy procedures.
Genitourinary System-Denies urinary frequency, oliguria, polyuria, dysuria, hematuria, pyuria, incontinence, or flank pain.
Menstrual and Obstetrical: Last Normal Period: 9/14 ended 9/19
Nervous System – Denies headache, seizures, loss of consciousness, ataxia, loss of strength, change in cognition/ mental status/memory, weakness, and sensory disturbances such as numbness, paresias, dysesthesias, and hyperesthesias.
Musculoskeletal System– Lower back pain with no radiation. Denies deformity, swelling, or redness. Denies h/o arthritis.
Peripheral Vascular System – Denies coldness or trophic changes, varicose veins, peripheral edema, or color change.
Hematologic System- Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions or history of DVT/PE.
Endocrine System- Denies polyuria, polydipsia, polyphagia.Denies heat or cold intolerance, goiter, excessive sweating, or hirsutism.
Psychiatric- Seeing a mental health professional once a week. Denies feelings of helplessness or hopelessness, lack of interest in usual activities or suicidal ideation. Denies anxiety, obsessive / compulsive disorder, or use of psychiatric medications.
