NR 509 Week 1 Comprehensive Health History Write-Up Example

Comprehensive Health History: A 52-Year-Old School Bus Driver Who Says She Is "Done by Two o'Clock," With Every Review of Systems Question Recorded as Asked

Student Name

College of Nursing, Chamberlain University

NR 509: Advanced Physical Assessment

Instructor Name

Month Day, Year

Comprehensive Health History: A 52-Year-Old School Bus Driver Who Says She Is "Done by Two o'Clock," With Every Review of Systems Question Recorded as Asked

Identifying Data and Source

Ms. L. R., 52-year-old woman, school bus driver, new patient establishing primary care. Source: the patient, who appeared reliable and gave a consistent account; her pharmacy printout was reviewed. Interview conducted in English, in person, 40 minutes. The structure follows the standard adult comprehensive history (Bickley et al., 2021).

Chief Complaint

"I'm done by two o'clock. I used to be able to do the afternoon run and then garden, and now I just want to sit in the car."

History of Present Illness

Onset: Gradual, over about five months, starting in the spring. No clear precipitating event.

Location and character: Generalized tiredness rather than sleepiness; she describes her legs as "heavy" and feels she has "no gas." She denies falling asleep while driving or at red lights.

Duration and timing: Present most days, worst in the early afternoon, improves slightly in the evening. Weekends are no better than weekdays.

Aggravating and relieving factors: Worse after climbing the bus steps repeatedly during the afternoon route; a 20-minute nap does not help. Coffee helps briefly.

Associated symptoms: Reports feeling cold when others are comfortable, dry skin, and constipation over the same period. Reports weight gain of about 8 pounds without change in diet. Heavier menstrual periods over the past year, now irregular. She has had no fevers or drenching sweats at night, no chest pain, no breathlessness while sitting still, and no blood in or blackening of her stool.

Treatments tried: A daily multivitamin from the pharmacy for two months, with no improvement.

Effect on function: Has stopped gardening and turned down an extra field-trip route. Worries about her safety driving children if it gets worse.

Patient's own explanation: "I thought it was menopause, but my sister said to get checked."

Past Medical, Surgical and Medication History

Medical: Hypertension diagnosed at 46, treated. Gestational diabetes in her second pregnancy, at 31; not followed up since. No known thyroid disease, anemia, kidney or liver disease. Surgical: Cesarean delivery at 31; laparoscopic cholecystectomy at 44. Hospitalizations: Only for the above. Immunizations: Tetanus-diphtheria-pertussis about 8 years ago; influenza yearly through her employer; unsure of COVID-19 boosters; has not had shingles or pneumococcal vaccines. Screening: Mammogram 3 years ago, normal; cervical screening 5 years ago, normal by her report; has never had colorectal cancer screening.

Medications: Lisinopril 20 mg by mouth once daily (confirmed on pharmacy printout); multivitamin daily; ibuprofen 400 mg for aching knees, by her estimate on two or three days each week. No herbal products. No recent antibiotics.

Allergies and Family History

Allergies: Penicillin, causing a raised itchy rash as a child; no breathing difficulty or swelling. Denies any food allergy; no reaction to latex gloves at dental visits.

Family history: Mother, 78, living, hypothyroidism and type 2 diabetes. Father died at 70 of a heart attack; had hypertension. Sister, 55, with "thyroid problems," type not known. Brother, 49, healthy. Two children, 24 and 21, healthy. No family history of colon cancer, breast cancer, anemia or bleeding disorders known to her.

Social History

Living situation and relationships: Lives with her husband, a mechanic, in a single-story house; children live nearby. Describes the marriage as supportive.

Work: School bus driver for 14 years, split shift from 0600 to 0900 and 1400 to 1700. Holds a commercial driver's license requiring periodic medical certification.

Habits: Never smoked. Has a glass of wine, occasionally two, on Friday or Saturday evenings and none on workdays; denies binge drinking. No recreational drug use. Two cups of coffee each morning.

Diet and activity: Eats fast food on split-shift days. Walked 30 minutes most evenings until the spring; now rarely.

Sleep: In bed 2130 to 0500, about 7 hours; husband reports she snores but has not noticed pauses in breathing.

Mood and stress: Denies feeling down or hopeless most days; reports irritability related to fatigue. PHQ-2 score 1.

Safety and resources: Wears a seatbelt; smoke detectors present; no firearms at home. Feels safe at home. Employer health insurance; no difficulty affording medications.

Sexual and reproductive: Sexually active with husband; perimenopausal with heavier, irregular bleeding over the past year; last menstrual period five weeks ago.

Review of Systems

Each system lists the specific questions asked, with the answer.

General: Fatigue as above; weight gain of about 8 pounds; denies fever, chills, night sweats.

Skin, hair, nails: Dry skin, yes; hair thinning, "maybe"; denies new rashes, itching or changes in moles.

Head, eyes, ears, nose, throat: Denies headaches, vision change, hearing loss, nosebleeds, sore throat. Reports a hoarse voice some mornings. Denies neck swelling or difficulty swallowing.

Cardiovascular: Denies chest pain or pressure, palpitations, fainting, leg swelling, pain in the calves when walking.

Respiratory: Denies cough, wheeze, shortness of breath at rest; reports breathlessness climbing two flights of stairs, new this year.

Gastrointestinal: Constipation, stools every three days, previously daily; denies abdominal pain, nausea, blood in stool, black stools, heartburn.

Genitourinary: Denies painful urination, frequency, incontinence. Nocturia once a night.

Gynecologic: Heavier periods over the past year, changing a pad every two to three hours on heaviest days; irregular cycle; no bleeding after intercourse.

Musculoskeletal: Bilateral knee pain with stairs; denies joint swelling, morning stiffness over 30 minutes, muscle cramps.

Neurologic: Denies numbness, tingling, weakness in one side, tremor, memory problems. Denies dizziness while driving.

Hematologic: Denies easy bruising or prolonged bleeding apart from heavy periods; denies craving ice.

Endocrine: Cold intolerance, yes; denies heat intolerance, excessive thirst, excessive urination.

Psychiatric: Denies depressed mood, loss of interest, anxiety attacks, thoughts of self-harm.

What the History Already Suggests

The history alone points in several directions that the examination and tests will need to sort out. Cold intolerance, dry skin, constipation, weight gain, hoarseness and a mother and sister with thyroid disease raise the question of hypothyroidism. Heavier periods over a year raise the question of iron deficiency anemia, which could also explain fatigue and breathlessness on stairs. A history of gestational diabetes with no follow-up means diabetes should be screened for. Snoring raises, less strongly, the question of sleep apnea, which matters particularly for a commercial driver. The examination should therefore include the thyroid, skin, conjunctivae and nail beds, and the plan should include testing guided by these findings.

Two gaps in the history should be filled at the next visit rather than guessed at: the date and result of her last blood count, which she cannot recall, and whether her snoring includes pauses in breathing, which her husband can be asked about directly.

References

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.