NR-304: Health Assessment II RUA: Health History
Part I: Comprehensive Health History
Biographical Data
• Name: Eleanor Vance
• Address: 123 Maple Street, Anytown, IL 60500
• Phone: 555-123-4567
• Age: 58
• Date of Birth: April 15, 1967
• Gender: Female
• Marital Status: Married
• Race: Caucasian
• Ethnic Origin: German-American
• Occupation: High School Librarian (currently employed)
• Primary Language: English
• Primary Source of Information: Patient, who is alert, oriented, and a reliable historian.
Reason for Seeking Care (Chief Complaint)
"I'm here for my routine follow-up for my high blood pressure and diabetes."
History of Present Illness (HPI)
Mrs. Vance is a 58-year-old female with a 10-year history of hypertension (HTN) and a 5-year
history of Type 2 Diabetes Mellitus (T2DM).
• Onset: She is here for a scheduled 3-month follow-up to monitor her chronic conditions.
• Location: The conditions are systemic. However, she reports specific symptoms
of "tingling and numbness, like pins and needles" in both feet, which is worse at
night. She also reports generalized fatigue, which is most pronounced in the late
afternoon.
, [Type here]
• Duration: The conditions are chronic. The tingling in her feet has been gradually
worsening over the past year. The fatigue has been present for several years but seems
more significant in the last 6 months.
• Characteristics: She describes the foot sensation as a "constant buzzing that sometimes
feels like a mild burn." The fatigue is a "drained, heavy feeling."
• Aggravating Factors: The foot tingling is worse at night and when she has been sitting
for long periods. The fatigue is aggravated by stress at work and days when she "eats
poorly."
• Alleviating Factors: She finds that moving around or walking helps the foot sensation
temporarily. Resting helps the fatigue, but she denies taking naps.
• Related Symptoms: She reports occasional blurry vision, especially when she feels her
"sugar is high." She also notes increased thirst (polydipsia) and urinating 2-3 times per
night (nocturia) when her blood glucose is poorly controlled. She denies chest pain,
palpitations, or shortness of breath at rest.
• Treatments: She reports "fair" adherence to her medications: Lisinopril for HTN,
Metformin for T2DM, and Atorvastatin for hyperlipidemia. She checks her blood glucose
using a glucometer at home 1-2 times per day, with fasting readings ranging from 110-
140 mg/dL and postprandial readings "sometimes up to 200." She states, "I know I should
watch my diet better, but it's hard."
Past Medical History (PMH)
• Childhood Illnesses: Varicella (chickenpox). Denies history of measles, mumps, rubella,
or polio.
• Adult Medical Illnesses:
o Hypertension (HTN), diagnosed at age 48.
o Type 2 Diabetes Mellitus (T2DM), diagnosed at age 53.
o Hyperlipidemia, diagnosed at age 53.
• Hospitalizations:
Part I: Comprehensive Health History
Biographical Data
• Name: Eleanor Vance
• Address: 123 Maple Street, Anytown, IL 60500
• Phone: 555-123-4567
• Age: 58
• Date of Birth: April 15, 1967
• Gender: Female
• Marital Status: Married
• Race: Caucasian
• Ethnic Origin: German-American
• Occupation: High School Librarian (currently employed)
• Primary Language: English
• Primary Source of Information: Patient, who is alert, oriented, and a reliable historian.
Reason for Seeking Care (Chief Complaint)
"I'm here for my routine follow-up for my high blood pressure and diabetes."
History of Present Illness (HPI)
Mrs. Vance is a 58-year-old female with a 10-year history of hypertension (HTN) and a 5-year
history of Type 2 Diabetes Mellitus (T2DM).
• Onset: She is here for a scheduled 3-month follow-up to monitor her chronic conditions.
• Location: The conditions are systemic. However, she reports specific symptoms
of "tingling and numbness, like pins and needles" in both feet, which is worse at
night. She also reports generalized fatigue, which is most pronounced in the late
afternoon.
, [Type here]
• Duration: The conditions are chronic. The tingling in her feet has been gradually
worsening over the past year. The fatigue has been present for several years but seems
more significant in the last 6 months.
• Characteristics: She describes the foot sensation as a "constant buzzing that sometimes
feels like a mild burn." The fatigue is a "drained, heavy feeling."
• Aggravating Factors: The foot tingling is worse at night and when she has been sitting
for long periods. The fatigue is aggravated by stress at work and days when she "eats
poorly."
• Alleviating Factors: She finds that moving around or walking helps the foot sensation
temporarily. Resting helps the fatigue, but she denies taking naps.
• Related Symptoms: She reports occasional blurry vision, especially when she feels her
"sugar is high." She also notes increased thirst (polydipsia) and urinating 2-3 times per
night (nocturia) when her blood glucose is poorly controlled. She denies chest pain,
palpitations, or shortness of breath at rest.
• Treatments: She reports "fair" adherence to her medications: Lisinopril for HTN,
Metformin for T2DM, and Atorvastatin for hyperlipidemia. She checks her blood glucose
using a glucometer at home 1-2 times per day, with fasting readings ranging from 110-
140 mg/dL and postprandial readings "sometimes up to 200." She states, "I know I should
watch my diet better, but it's hard."
Past Medical History (PMH)
• Childhood Illnesses: Varicella (chickenpox). Denies history of measles, mumps, rubella,
or polio.
• Adult Medical Illnesses:
o Hypertension (HTN), diagnosed at age 48.
o Type 2 Diabetes Mellitus (T2DM), diagnosed at age 53.
o Hyperlipidemia, diagnosed at age 53.
• Hospitalizations:
