The patient reports increased pressure at work from a new and demanding boss; she is also worried about her daughter (see Personal and Social History). Thinks her headaches may be like those in the past, but wants to be sure because her mother died of a stroke. She is concerned that they interfere with her work and make her irritable with her family. She eats three meals a day and drinks three cups of coffee per day; cola at night.
■ Medications. Aspirin, 1 to 2 tablets every 4 to 6 hours as needed. "Water pill" in the past for ankle swelling, none recently.
■ *Allergies. Ampicillin causes rash.
■ Tobacco. About 1 pack of cigarettes per day since age 18 (36 pack-years).
■ Alcohol/drugs. Wine on rare occasions. No illicit drugs.
Childhood Illnesses. Measles, chickenpox. No scarlet fever or rheumatic fever.
Adult Illnesses. Medical: Pyelonephritis, 1982, with fever and right flank pain; treated with ampicillin; develop generalized rash with itching several days later. Reports kidney x-rays were normal; no recurrence of infection. Surgical: Tonsillectomy, age 6, appendectomy, age 13. Sutures for laceration, 1991, after stepping on glass. Ob/gyn: G3P3, with normal vaginal deliveries. 3 living children. Menarche age 12. Last menses 6 months ago. Little interest in sex, and not sexually active. No concerns about HIV infection. Psychiatric: None.
Health Maintenance. Immunizations: Oral polio vaccine, year uncertain; tetanus shots x 2, 1991, followed with booster 1 year later; flu vaccine, 2000, no reaction. Screening tests: Last Pap smear, 1998, normal. No mammograms to date.
A note on recording the Family History. There are two methods of recording the Family History: a diagram or a narrative. The diagram format is more helpful than the narrative for tracing genetic disorders. The negatives from the family history should follow either format.
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