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Faridah Nabibaks

68 yrs old

8/31/1949

New Patient, recently moved into the area

HR 86

BP: 135/85

Temp: 98.6

RR: 22

First time patient

Chief Complaint: Misplaced inhaler: need fluticasone and albuterol

Also having back pains for about 5 years intermittently and has never talked to physicians about it

- Occurs once every 2-3 months, takes a few days, and can be a bit of a problem
- Moved in for family and 4 grandchildren and daughter and son who both live in the area
- Had an astma attack last week, went to the ER,and is on prednisone as a result
- Lost 1-2 inches of height
- Came to the island 6 months ago after retirement and had back pain on the island about 5
months ago
- Back pain is a dull and achy pain
- Located in the Middle and lower back
- It localizes there
- Didn’t fall, trip or lift anything
- Pain is rated 5/10; Not a big complainer
- Had asthma for 30 years
- Can’t move as much with pain, take ibuprofen/acetaminophen and just lie down
- Has a rental, has a car, daughter doesn’t want to see anyone, son is the same
- Divorced; and is involved with a woman. Has had a girlfriend for the last 5 months
- Is worried that daughter doesn’t want her around the grandchildren for this influence
- Thinks she’s just getting older, and that’s what’s causing all this
- Gets shortness of breath, does a little cooking/sweeping, but can’t do as many activities as she
used to
- Expects an inhaler from todays visit & get rid of the back pain
- Had an asthma attack a week ago & drove herself to the ER and they put her on a nebulizer. She
was afraid to call her daughter when she had the attack
- Morning cough (clear) to get rid of some phlegm
- No known allergies
- Had a C-section 2x, had appendix removed, and had tonsils removed
- No injuries/traumas No childhood illnesses
- Asthma/SOB for 30 years
- Had screenings 5 years ago.
- Pap smear (no), Colonoscopy (no)
- Mom died of a stroke
- Dad passed away of a heart attack
- Sons and daughter are healthy
- No knowledge of grandparents’ health history
- Has a gropu of retired teachers in her building, and her girlfriend that she normally talks to
- Is a Baptist, and hasn’t gone to church in a while
- Concerned with church view on same-sex relationship, but misses church
- Lives in a one-bedroom apartment with a sea view
- Pays for it with her pension money/savings
- Used to be a 3rd grade teacher for years
- Eats well: vegetables, fruits, not too much fried foods
- Sleep: 7 hours of sleep for years
- Alternative medicine: none & has never tried it
- Sexually active with her partner
- Oral yes, Anal no, Vaginal yes
- Have known each other for last 5 months and don’t use protection
- Went to a clinic close by and had blood tested
- Trusts her Girlfriend and vice versa
- Back pain doesn’t affect performance
- Doesn’t have sex when she has back pain
- Has never had any STIs in the past
- Has never asked partner if she’s never had one either
- Post-Menopausal
- Had last period when she was 52
- No alcohol
- Drinks a few cups of coffee a day
- Quit smoking 7 years ago
- Started smoking in her 20s and smoked a pack a day
- Has felt hopeless/depressed in the last 2 weeks because of the relationship with her daughter

Review of systems
- No fever/chills
- Gained 2lbs
- No fainting
- No changes of skin/hair/nails
- Had mammogram 25 years ago, but no breast changes
- Wheezing during asthma attack
- No chest pains/hear racing
- No ankle swelling
-No difficulty swallowing
- No nausea/ vomiting
- No pain/tenderness

Medication

Flucatisone/Salmeterol 250mcg/50mcg