Complete History #1
Subjective (Prenatal Patient)
Source and Reliability: 27 y/o Caucasian Female
Chief Complaint: The patient arrived in the emergency department and has been experiencing contractions for the past two days. Currently, her contractions are 12 minutes apart. She is 33 weeks pregnant.
History of Present Illness (HPI): Ms. T.R. is a 27 y/o full time nurse. She is pregnant for the second time but experienced a miscarriage with her first pregnancy. She was diagnosed with hypertension in her 12th week of pregnancy and has been advised to alleviate her stress levels as much as possible, particularly since she miscarried in 2011. T.R. is otherwise healthy and has no known prior history of serious medical conditions. Up until the chief complaint, T.R. did not experience any contractions or cramping. However, she has been very concerned throughout her entire pregnancy due to her past miscarriage, which was not attributed to any specific health condition. Approximately 48 hours ago, T.R began to experience what she believed were contractions, but they were infrequent and she was not alarmed at their onset. However, as time passed and the contractions became more frequent, it was strongly recommended that she come into the emergency department to determine if she was in early labor.
OB Risk Assessment:
Past Medical History:
General State of Health: General good health, weight is in the normal range, pregnancy weight gain is normal; good nutrition and exercises regularly
Past Illnesses: Chicken pox at age 9; tonsillectomy at age 12; history of strep throat and ear infections as a child; no known serious illnesses as an adult
Injuries: Broken arm in 2004 after falling off bicycle
Hospitalizations: Admission for tonsillectomy; admitted for overnight observation after miscarriage
Allergies: Cat hair; no known drug allergies
Diet: Vegetarian; has not consumed meat since 2008; also low sodium to monitor hypertension
Sleep Patterns: Sleeps approximately 6-7 hours per night; sleep is sound
Current Medications: Prenatal vitamin 1x daily; Zantac 75 as needed for acid reflux; ibuprofen as needed
Alternative Therapies: None
Health Maintenance: Prior to pregnancy, received annual physicals; has been strong in keeping her required prenatal appointments throughout the pregnancy
Occupational and Environmental History: Has been employed as a med/surg nurse for five years at a 200-bed facility in a busy metropolitan area. There is no known environmental concerns at work or in the home environment, other than normal risks.
Father (age 59): History of hypertension (10 years); high cholesterol
Mother (age 58): history of type 2 diabetes (5 years); high cholesterol; overweight (200 lbs).
No siblings; family history of bladder cancer (grandfather) and colon cancer (uncle)
Psychosocial and Spiritual History: Grew up Catholic but is not currently practicing or attending mass; high levels of stress with job; depressive symptoms after miscarriage and entered psychotherapy for six months
Sexual, Reproductive, Obstetric and Gynecologic History: Miscarriage in 2011 at 7 weeks without D&C; prior to pregnancies, was prescribed Norethindrone (Micronor) for contraceptive purposes; normal periods approximately 6 days in length
REVIEW OF SYSTEMS (ROS)
Skin: Skin is dry around hands and feet; otherwise normal
Head: Occasional headaches due to stress but no known migraines
Eyes: Vision has declined in recent years when reading; uses non-prescription reading glasses for this purpose
Ears: No known or obvious hearing loss; numerous ear infections as a child but none as an adult
Nose: No obstruction or epistaxis
Mouth and Throat: History of strep throat and tonsillectomy at age 12; wore Invisalign between 2010-2012 to straighten teeth; two root canals/crowns in 2006 and 2009
Neck: No visible lumps or lesions
Chest: No history of asthma or cough, pleurisy or wheezing; TB test annually required for job, negative result
Cardiac: No known prior chest pain, heart sounds normal
Vascular: No known history of deep vein thrombosis or aneurysm; no visible varicose veins
Breasts: No known history of lumps or cancer; no mammograms to date
GI: Occasional acid reflux symptoms, particularly after consuming spicy foods (likes Indian food)
Urinary: Two past UTIs over five years; prescribed Ciproflaxcin 500 mg for 7 days for each occurrence as recommended by guidelines (Mehnert-Kay, 2005)
Genitalia: No visible rashes, lesions; cervix is effaced (The American College of Obstetricians and Gynecologists, 2013)
Musculoskeletal: Occasional pain in ankles after taking long walks; possible tendonitis in left inner ankle; no other musculoskeletal concerns
Neurologic: No known neurological concerns; occasional headaches are alleviated with rest and/or ibuprofen
Complete History #2
Subjective (Pediatric Patient)
Source and Reliability: 13 y/o African American Female
Chief Complaint: The patient arrived in the emergency department after experiencing severe headaches, cold hands and feet, and pale skin over the past three days. She is also experiencing pain in the joints, complaining of several flare-ups throughout the day. She has been unable to sleep soundly through the night due to the pain in her joints.
History of Present Illness (HPI): The patient, C.D., is a 13 y/o African American female. She was diagnosed with sickle cell anemia at age two. She is typically prescribed antibiotics when any sign of cold or other infection is present. She has been visiting her hematologist every three months for the past 11 years. She has also received all required vaccinations as necessary. When C.D. experiences flare-ups in her joints that lead to mild pain, her mother gives her children’s Tylenol to alleviate these symptoms. However, she has also required overnight hospitalization on 11 different occasions since her diagnosis for severe pain and fluid management after being diagnosed with dehydration. C.D. has also required blood transfusions due to splenic crisis on four different occasions. C.D.’s height and weight are low and she ranks in the 40th percentile in both areas. In spite of her condition, she is accustomed to the disease and knows that hospitalization is sometimes necessary to manage her symptoms. In spite of her medical needs, she has a positive attitude regarding her illness and her limitations.
Birth History: Born in April 2000; normal pregnancy and childbirth
Past Medical History: Diagnosed with sickle cell anemia in 2002 after requiring hospitalization for severe pain and dehydration. Hospitalized 11 times for the condition to date, including four times for splenic crisis to receive blood transfusions. Joint inflammation is the chief routine concern, which may cause significant pain flare-ups in her joints (Rees et.al, 2010). She has been hospitalized almost annually since her diagnosis, with the exception of hospitalization twice in 2005 and no hospitalizations in 2006. In spite of her condition and its complications, the quality of life is relatively stable (Wang et.al, 2011). Splenic crises occurred in 2003, 2005, 2008, and 2010, requiring hospitalization for several days each time. CBC counts were abnormally low upon diagnosis of each splenic crisis. Blood transfusions have been required; however, the physician has not determined that splenic removal is required at this time. Joint pain is somewhat regular, with intervals of mild and severe pain every few months. The patient requires pain medication under these conditions, and has been hospitalized on two occasions for severe pain in the joints.
Nutrition: The patient has been prescribed a high-calorie diet during calm periods, as well as nutritional supplements because the condition leads to low energy levels and loss of appetite when flare-ups are likely to occur.
Growth and Development: Due to the patient’s condition, height and weight are both in the 40th percentile range. C.D. is 52 inches tall and weighs 76 pounds. She has not experienced the growth spurt that is expected for a female of her age.
Immunizations: All required immunizations have been obtained as necessary to minimize the risk of future infections.
Social and Environmental: The patient has a stable home life and both parents participate in her care and treatment regimen. She has a few friends at school that she sees pretty regularly but has missed school frequently over the years. Upon periods of hospitalization, her teachers provide her assignments so she is able to complete them at home. However, she is as social as possible and does participate in classroom activities and team exercises enthusiastically as a result of her positive attitude. She cannot participate in athletic activities due to her condition, but she is a member of the Girl Scouts and participates in meetings as much as possible. Her family practices clean living in the household to minimize the spread of any possible infections. This also includes the use of air purifiers in the patient’s bedroom and in all common areas of the house. The patient’s older sister (age 17) is also instrumental in providing support to C.D., particularly during health crises and periods of hospitalization.
Father (age 42): type 2 diabetes, diagnosed at age 40, controlled by diet and exercise; high cholesterol (Lipitor 20mg 1x/daily); normal weight; high stress at work (defense attorney)
Mother (age 41) miscarriage between older daughter’s birth and C.D.’s birth; hypertension controlled by medication (Lisinopril 10mg 1x/daily); overweight (approx. 175 lbs.); high stress at work (critical care nurse)
Sister (age 17): allergic to penicillin, no other prior serious health concerns
Review of Systems (ROS):
General: Health has been challenging since age 2, with frequent hospitalizations and treatments required to manage sickle cell disease and to minimize symptoms and frequency of flare-ups
Skin: pale and cold to the touch
HEENT: Headaches on occasion, mild to severe; does not wear glasses, 20/20 vision in last eye examination in 2012, no eye pain; no obvious hearing loss, no history of ear infections; No nasal obstructions; no prior history of strep throat or required tonsillectomy; Wears braces to straighten teeth; no current cavities
Heart: Heart sounds normal, heart rate is 86
Respiratory: No prior history of asthma; occasional cough during flare-ups; no prior history of exposure to TB or pneumonia
Abdomen: Abdominal tenderness, normoactive bowel sounds, pain upon touch to abdominal area
GU: No prior history of sexual activity; menstruation began at age 12; periods are heavy and lengthy (7 days or more); pain and cramping during the first few days of the menstrual cycle
Skin: Skin is pale and cold to the touch; feet are abnormally cold
Musculoskeletal: Lengthy history of joint pain and inflammation; pain in legs and feet regularly, some periods more severe than others; pain in abdomen during splenic crises; cramping in hands after using hands for long periods, such as writing
Neurologic: No known neurologic conditions or risk factors
The American College of Obstetricians and Gynecologists (2013). Preterm labor and preterm Birth. Retrieved from http://www.acog.org/~/media/For%20Patients/faq087.pdf?dmc=1&ts=20130922T2301383850
Mehnert-Kay, S.A. (2005). Diagnosis and management of uncomplicated urinary tract infections. American Family Physician, 72(3), 451-456.
Rees, D.C., Williams, T.N., and Gladwin, M.T. (2010). Sickle-cell disease. The Lancet, 376(9757), 2018-2031.
Wang, C.J., Kavanagh, P.L., Little, A.A., Holliman, J.B., and Sprinz, P.G. (2011). Quality-of-care indicators for children with sickle cell disease. Pediatrics, 128(3), 484-493.