Charles is a 79 yo male, retired, former maintenance worker, married to Betty for the past 56 years. They had 2 children; one died an accidental death at age 22. Their son Rob lives in the same city--Seatac. They have 3 grandchildren and 2 great grandchildren. Charles has well-controlled HTN and DM type 2. His history includes the following information:
Diet: Wife cooks. Tries to eat a low fat, low cholesterol diet, likes fruits but doesn’t eat a lot of vegetables, coffee 2 cups a day. Struggles with his weight.
Elimination: No concerns
Sleep: Sleeps 8-9 hours a night
Habits: Former smoker, drinks occ. beer, exercises with evening stroll walking dog around the block.
Meds: Lisinopril 20 mg a day
Metformin 1000 mg twice daily
Allergies: NKDA
Patient Profile: Lives with wife in their own home, 3 grandchildren, 2 great grandchildren. Supports include wife and son.
ROS: HTN past 5 years, well controlled on medication, DM type 2, dx’d 4 years ago, initially diet controlled, on metformin past 2 years.
Family Hx: Mother: HTN, died age 85 from stroke
Father: unknown
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Betty:
Betty is a 78 yo female, retired, married to Charles for the past 56 years. They had 2 children; one died an accidental death at age 22. Their son Rob lives in the same city. They have 3 grandchildren and 2 great grandchildren. Her health is generally good except for early signs of dementia with some memory loss. Her history includes the following information:
Diet: Tries to cook low fat, low cholesterol diet; 2-3 servings fruit/vegetables per day and 1glass nonfat milk per day. Caffeine= 2-4 cups per day; no caffinated soda or tea.
Elimination: Generally no problems
Sleep: Usually sleeps through night unless wakes up once to use the bathroom
Habits: Non-smoker
ETOH: Occasional glass of wine.
Enjoys gardening
Meds: Multivitamin 1/day
Allergies: PCN (hives), house dust
Patient Profile: Lives with husband in their own home, 3 grandchildren, 2 great grandchildren. Supports include retired husband and son.
ROS: Vision well corrected with bifocals. Last eye exam 2 yrs ago; hearing good; no upper or lower respiratory symptoms, no change in bowel habits or GI probs. Menopause age 53, P2,G2. Hx breast CA age 62, treated with lumpectomy and radiation, no recurrence.
Family Hx: Mother: Died age 85 pneumonia
Father: Died age 60, MVA, had HTN, ? CAD
Maternal grandmother: ??Dementia
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Rob:
Rob is a 54 year-old Caucasian male bus driver. He lives in Seatac. He has well-controlled hypertension and struggles with his weight, but overall feels well. He divorced Sally 20 years ago. They have 2 sons, grown and living on their own. He is now married to Lupe. They have a 17 year old daughter who lives with them. He has a fairly sedentary lifestyle. His history includes the following information:
Diet: "Meat and potato man". Wife cooks a variety including fruits and vegetables. Limits eggs to 4 a week, likes ice cream every evening as snack. Eats doughnuts almost daily. 5-6 cups coffee day. Salts food.
ETOH: 1-2 beers a day. Sometimes 3-4 on weekend night. No hard liquor except during holidays.
Exercise: Minimal exercise. Does odd jobs around the house, "Could drop a few pounds. I'm at 180 lbs and that's the most I've ever weighed."
Sexuality: 2nd marriage. Currently monogamous, satisfying relationship
Smoking: x 20 yrs. Originally 2 ppd, decreased to 1ppdx last 5yrs. Not many attempts at quitting.
Rest: Sleeps 8hrs. noc. Often naps after dinner.
Support: Mainly wife.
Stress: Describes as "moderate" due to planning for retirement. Would like to be a little more financially secure.
Family Hx: Mother: Early dementia (memory loss), otherwise healthy
Father: HTN and DM type 2
Brother: Accidental death at age 22
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Sally:
Sally is a 53 yo female, part time office worker. Her health is good. She and Rob divorced 20 years ago. She did not remarry. She lives on her own in Seattle. She and Rob have 2 grown sons who are living on their own. Her history includes the following information:
Diet: Vegetarian, does eat dairy and eggs
ETOH: Does not drink alcohol.
Exercise: Walks her dog after work. Recently joined a gym.
Sexuality: Not currently in a relationship.
Smoking: Non-smoker
Rest: Sleeps 8hrs. noc.
Support: Support from friends, church, sons
Stress: Worries about retirement, has little savings.
Family Hx: Family hx: Unknown, adopted.
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Lupe:
Lupe is a 45 yo female, currently married to Rob. They have a 17 yo daughter who lives with them. Lupe is generally healthy, but struggles with depression and is currently on medication for this. She worries about her daughter getting into trouble and the relationship is tense at times. She was recently laid off from her work as a medical assistant.
Diet: Considers her diet well balanced.
ETOH: Occasional beer when entertaining
Exercise: Walks with a close girlfriend 1-2 times a week
Sexuality: Monogamous relationship
Smoking: Non-smoker
Rest: Sleeps 8hrs. noc.
Support: Main support from husband and friends. Lives far from extended family.
Stress: Some concerns about retirement and stress over recently being laid off of work.
Family Hx: Mother: Depression
Father: DM type 2
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Chris:
Chris is a 31 year old male, construction worker.His general health is good. He lives with Maria, his wife of 5 years. They have 2 children, a 3 year old boy and a 1 year old girl. His history includes the following information:
Diet: Likes meat in his diet, not big on vegetables
ETOH: 2 beers every evening after work, more on weekends
Exercise: Considers his job exercise, sedentary when home
Sexuality: Monogamous, satisfying relationship
Smoking: Occ. smoker when out with friends, not daily
Rest: No issues with sleep
Support: Wife, group of close male friends
Stress: Some worries about job insecurity during tough economic times, no benefits with current job
Family Hx: Mother: Healthy
Father: HTN, overweight
Brother: Healthy
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Maria:
Maria is a 30 year old female, stay at home mom. She lives with Chris, her husband of 5 years. She is bilingual with Spanish and English. She has 2 children, a 3 year old son and a 1 year old daughter. Her parents and siblings live in Mexico. Her health is generally good but she does have asthma and seasonal allergic rhinitis. Her history includes the following information:
Diet: Varied, cooks some traditional Mexican foods, tries to bring vegetables into daily diet though husband prefers meat.
ETOH: rare
Exercise: Playing with children
Sexuality: Monogamous, satisfying relationship
Smoking: Non-smoker
Rest: Sleep occasionally interrupted by one year old daughter
Support: Husband, friends
Family Hx: Mother: Healthy
Father: Asthma
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Kelsy:
Kelsy is a 17 yo female, high school student. She attends Tyee High School in Seatac. She lives with her parents. She is in 11th grade. She is healthy. Her history includes the following information:
Diet: Skips breakfast, school lunches or fast food, dinner with family if home
ETOH: Drinks with friends on weekends
Exercise: No team sports. No regular exercise.
Sexuality: Boyfriend of 1 year.
Smoking: Nonsmoker, has tried MJ.
Rest: No sleep issues
Support: Main support is friends, gets along well with father, some tension with mom
Stress: School, tension with mom
Family Hx: Mother: Depression
Father: HTN
Paternal grandfather: HTN, DM type 2
Paternal grandmother: Early dementia, breast CA
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Luis:
Luis is a 3 year-old mixed Caucasian/ Hispanic male, son of Chris and Maria. You are seeing him for a Well Child Check. He is accompanied by his mother and 12-month old sister. Mother states "I think he's behind on his shots" and she desires a full check-up. Luis lives with his parents and sister. His father works in construction. His mother stays home. Luis was last seen 2 months ago in the emergency room for stitches when he cut his forehead in a fall from the porch. He has a history of asthma and eczema, well controlled currently. His history includes the following:
Diet: Eats all table food, especially likes tortillas, cheese, fruits, not vegetables. Drinks whole milk - 8 ounces with each meal. Drinks soda on weekends, some candy, no gum.
Elimination: Recently completed toilet training for bowel, dry during day and most nights; night wetting about once a week. Mom not concerned.
Sleep: Usually sleeps through night. Naps most days for an hour in afternoon.
Safety: Mom has Ipecac and gate for stairs, no cupboard locks or outlet protectors. Mom states Luis is very active and she can't be watching him every minute due to infant; states he "has to learn things the hard way."
Development: Dresses and feeds self. Can follow simple directions and likes to be a "helper". Parents have no concerns, but wonder about his speech. Describe him as an active, happy, loving little boy. Language- Mom states he babbles and sometimes says words that she can understand like "milk", "potty", "go", and "baby". Can follow her directions and she thinks he understands and hears well. Often points to what he wants. Spanish and English are used in the home.
Patient Profile: Family lives in Seatac, low to middle class neighborhood, renting home; many children in neighborhood. Luis plays well with others most of the time. Cared for by Mom at home. Watches TV 3-4 hours every day.
Immunizations:
Hep B x 3,
DtaP x 2,
IPV x 2,
Hib x 2,
MMR at 12 mos. which was last time he had "shots".
Family Hx: Mother: Asthma, allergic rhinitis
Grandfather: HTN
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Ana:
Ana is a 1 yo female, daughter of Chris and Maria. She has a 3 yo brother, Luis. Her health is good. Her history includes the following:
Diet: Breastfed. Has now transitioned to whole milk. Eats a variety of table foods.
Elimination: No concerns.
Sleep: Occasionally wakes at night. Back to sleep with comfort from mom.
Safety: Mom has Ipecac and gate for stairs, no cupboard locks or outlet protectors.
Development: Meeting developmental milestones for age.
Patient Profile: Family lives in Seatac, low to middle class neighborhood, renting; many children in neighborhood. Spanish and English are used in the home.
