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History: Mrs. Heart

Here is the information that you were able to gather from the interview

Identifying Data

Mrs. Heart is 60 years old woman who recently retired from her work as a high school teacher 5 years ago. Mr. and Mrs. Heart have been married for 42 years and they have 2 daughters, 2 sons and 3 grandchildren.

Chief complaint

She is feeling unwell, as she has back pain, nausea and extreme fatigue.

History of the present illness

Mrs. Heart tells you she has never had angina episodes before. Usually, when she feels unwell, she takes antacids and they are very effective. She attributes her present symptoms: fatigue, nausea and shortness of breath, to indigestion.

The pain is sharp and radiates to her abdomen, back, jaw and left arm. the discomfort started in the morning, when she was making her bed, but the pain increased in intensity while she was washing the dishes.

Past medical history

She was recently diagnosed with diabetes (type 2). She has hypertension, high LDL and low HDL. She has used hormone replacement therapy since her menopause, at 55 years of age. When she was younger, she was anemic. She started smoking at age 20 (4 packs/week), but stopped 5 years ago due to feeling shortness of breath (she has never mentioned it to her doctor before).

She consumes alcohol occasionally and moderately (once a month) when her children come to visit her. She loves to cook and has never thought about starting a diet to decrease her weight (BMI: 29).

Medications

Glyburide and metformin, estrogen and progesterone, beta-blockers for her hypertension, atorvastatin calcium, a multivitamin and occasionally, she takes antacids (Tums).

Family history

Her father died of a heart attack in his early sixties, and her mother died of cancer. Her daughter and her son are hypertensive and the son has had angina before.

Social history

Mrs. Heart attended university for 3 years and was a high school teacher for all of her working life. She retired 5 years ago. She lives with her husband of 42 years, with whom she has a good relationship. Her children live in the area and she sees them often. Mr. and Mrs. Heart are financially comfortable. Mrs. Heart is a devout Catholic and is very involved in the church. She is very concerned that her recent pain and the need for medication are interfering with her ability to care for, and enjoy, her family.