Partner Health History
Partner Health History
Partner Health History Paper
Marianne O’Brien
Stratford University
NSG330
Partner Health History Paper
Health History
Biographic Data
Name: A.S
Address: 1122 Stratford Place, Woodbridge, VA 22193 Date of Birth: 03/27/1963
Birthplace: Arlington, VA Marital Status: Married Occupation: Retired Race/ Ethnic Origin: White/ Caucasian
A.S is 57 year old female, she has been retired for 8 years.
Source:
Patient, seems reliable with husband, also seems reliable.
Reason for Seeking Care:
Increased Right sided UE and LE weakness, slurred speech.
History of Health/ Present Illness:
Previous CVA in September 2019 (MRI w/ and w/o contrast: acute lacunar strokes in anterior basal ganglia and internal capsule on left and in the left central pons; nonspecific small area of enhancement in right basal ganglia possibly from subacute strokes; old encephalomalcic changes in both frontal lobes. Bilateral carotid u/s: negative- no atherosclerosis plaque in either bifurcation region. On d/c she was started on baby aspirin 2x per day; since was discontinued by patient), residual weakness, requires use of cane for ambulation, chronic uncontrolled hypertension (currently untreated), hyperlipidemia; untreated due to medication noncompliance (last fasting lipid panel in 01/2019; total cholesterol at 178, triglycerides at 127, HDL at 42, LDL at 111), DM type 2: diet controlled.
Last HbA1c in 01/2019 at 5.7. Seizure disorder, previous EEG done at initial presentation of seizure event demonstrated right sided frontotemporal slowing and spiked discharges. Patient was found by husband approximately 0400, patient was laying on the couch, unable to stand, respond appropriately to questioning or speak coherently. Husband stated the room was in disarray, possibly from a fall. He also reports possible urinary incontinence with wet spot on the couch by the patient.
Patient ;
presented to ED with right upper and lower extremity weakness, slurred, speech and disorientation.
was unable to recall most of the night’s events, but states she fell on her buttocks.
also stated that she felt like she was speaking weirdly although she knew what she wanted to say. Husband reports that the right sided extremity weakness is considerably worse in regards to LE strength and ambulation. Patient admits to significant cocaine use and medication noncompliance since June 2019. Patient denies head trauma, headache, change in vision, n/v, dizziness, SOB, chest pain, or palpitations.
Past Health
General Health: Overweight
Chronic Illnesses: Seizure disorder, hyperlipidemia, hypertension, DM type 2
Accidents or Injuries: MVA as child (age 13) with concussion/ front lobe injury
Hospitalizations: September 2019 following CVA
Operations: 2 cesarean sections age 26 and 30 years old
Obstetric History: Gravida: 4 Term 4 Preterm 0 Ab/incomplete: 0 Living: 4
Course of pregnancies: 4 to term, 1982 male, 1984 male, 1986 cesarean female, 1991 cesarean female.
Immunizations: All up to date, No flu shot.
Last Exam Date: Physical 2019, Dental: 2015, Vision 2019
Allergies: none known
Current medications:
Non-compliant with current prescribed medication regimen. Prescribed baby aspirin 81mg every day, KCl 20 mEq PO every day, Zocor (simvastatin) PO 40mg every day hour of sleep. HCTZ 25mg PO every day, Lotrel (amlodipine/ benzapril) PO 10/20mg every day, no herbal medications or OTCs.
Family History: Mother: alive and well
Father: Deceased in mid 60’s of cancer, type is unknown
Otherwise family hx is unknown, no relationship with rest of family
Social History:
Patient is currently living with her husband, daughters and grandchildren. They have 4 children, 2 daughters live with her and husband. She maintains a relationship with her mother and 2 daughters but does not maintain relations with 2 sons and rest of family. Recently, she lost her medical insurance (Medicaid) and she cannot afford to see her PCP or follow up with physical therapy for CVA rehab. She is now in the process of applying for disability, she is retired but states that the financial help is not enough.
prescribed medications
Due to lack of finances she has been taking her prescribed medications since June of 2019. She has completed high school with her diploma and did receive an associate’s degree in IT. ADL’s are limited. Her husband prepares food and helps her bath but she maintains ability to perform essential tasks such as brushing teeth and feeding herself. She does report smoking ciggerettes, half a pack a day, and denies alcohol use. She does have a significant cocaine habit, smoking approximately once per week for the past 2 years, although her husband states that this has been going on for a lot longer.
