Improve Health History
please improve this job, correct mistakes and follow this instructions
I have reviewed your Health History submission and would like to go over it with you so you may improve your assignment before the due date. You can edit your assignment and resubmit it before the due date.
Under obstetrics, you want to ask your patient if they have children, how many, how were they delivered, if they suffered any miscarriages, when was their last menstrual period, are they in menopause, has she gotten a pap smear, what were the results of the pap smear.
I noticed you were missing your genogram. Do not forget to include that.
Under the Review of symptoms, you will use the same format as the guide provided but you would not just include “none” or only what she had. It should properly be written as ” Skin: Denies or reports rashes, lumps, sores, itching, dryness, color changes in hair or nails” if your patient suffered from something and not the other you can say ” Skin: reports rashes, lumps, sores, itching, dryness. Denies color changes in hair or nails”
According to APA, the bold titles such as “Review of systems” should be indented left and not in the middle. In your second page you should add a “Health History” (unbolded) in the center of the page and that is your title.
Under Patterns of healthcare, you want to include if your patient actively participates in preventative care such as annuals or going to the dentist, etc.
Remember to include identified risk factors and any health promotion activities. Also include what suggestions to made to their diet and what is their evaluation of their own diet (excellent, good, fair, poor).
If you have any questions, please do not hesitate to contact me.
Commentby Morgan, Dorothy Tali: Do not forget to include a running head to follow APA guidelines
Health History
Benjamin Leon School of nursing
NUR1060C: Adult Health Assessment
Professor Dorothy Morgan
April 7, 2021
Health History
Identifying data
Date of history: 28/02/2021
Examiner: Yensi Aguilar
Name: L.P.
Address: 3403 SW 6h Street
Phone Number: 786-
5
97-3071
Age:46
Sex: Female
Race: White
Place of Birth: Honduras
Marital Status: Married
Significant Other: Husband
Occupation: Teacher
Religion: Christian
Primary Language: Spanish
Secondary Language: English
Source of referral: The patient found the hospital’s address on the internet
Source of history: Documents with the patient’s health history gave information concerning the patient. The patient also talked concerning her health status.
Reliability: Currently, the patient seems to have a stable mental and physical state.
Chief Complaints/Reasons for Visit: According to the patient, she started experiencing high fever, blood-stained sputum, night sweats, coughing, and weight loss.
Present Illness
Time of onset: according to the patient, she started experiencing symptoms two weeks ago.
Type of onset: The patient says that she started by occasionally sweating, mild cough, headache, and pain in the abdomen area. Over time, these conditions became severe.
Original Source: The patient complains of pain in her chest and respiratory tract.
Severity: During the day, the patient does not feel many discomforts, but it becomes worse at night due to lower temperatures. Hence, the condition does not deter the patient from executing tasks during the day. The severity of her state is at 5 out of 10 on a 0-to-10-point scale.
Radiation: At night, the patient feels severe pain throughout her chest region
Time Relationship: At first, this condition was still developing and was easy to handle. However, it has evolved and has gotten worse.
Duration: It has been two weeks since the patient started experiencing the symptoms.
Association: The symptoms experienced by the patient are similar to those of flu.
Source of Relief: According to the patient, she feels better when resting after doing some light physical exercise.
Source of Aggravation: The symptoms become worse during the night. Again, exposure to allergens such as dust or cold increases the symptom’s severity.
Past History
General State of Health: The patient’s general condition is fair, considering she is suffering from a chronic illness.
Childhood Illnesses: She suffered from smallpox and measles as a child
Adult Illnesses: Hypertension, Anemia, and asthma
Psychiatric Illnesses: She has experienced mild depression in the past
Accidents and Injuries: Never had an accident or injuries
Operations: The patient denies any surgical operations
Hospitalizations: After visiting the hospital, the patient got an admission to the Jackson Hospital for one week to undergo treatment for asthma and hypertension. She received treatment and later discharged after the end of the 7th day. Healthcare providers advised her to quit smoking and taking alcoholic beverages.
Obstetric:
Do you have children? Yes
How many children do you have? Two
How did you deliver them? Natural delivery
Have you ever had a miscarriage? No miscarriages
When was your last menstrual period? 2 weeks ago
Are you in menopause? No
Have you had any recent pap smears? Yes, six months ago
What results did the pap smear give? Cancerous cells present
Family Genogram
5
Current Health Status
Current medication: the patient is currently taking hypertension and flu antibiotics medication such as azithromycin and acetaminophen. Comment by Morgan, Dorothy Tali: Put the specific medication with dosage, how many times a day, and route.
Allergies: the patient is allergic to fur and dust particles Comment by Morgan, Dorothy Tali: Include what reaction they get to the allergies
Screening tests: she has undergone throat and lung cancer screening Comment by Morgan, Dorothy Tali: Be specific. What tests did she complete, when, and what were the results
Immunizations: vaccines are up to date including influenzae
Family History
Maternal/Paternal Grandparents: both died from a natural illness Comment by Morgan, Dorothy Tali: What is natural illness mean? Be specific
Parents: Mother is 55 years old, diagnosed with Diabetes and hypertension. Her father died from cancer at age 62. At age 30, her father had a diagnosis with a mental disorder.
Aunts/Uncles: paternal uncles died from HTN. Paternal aunts are alive but diagnosed with mental disorders.
Siblings: 1 brother and three sisters Comment by Morgan, Dorothy Tali: Are the siblings healthy?
Spouses: Husband is alive and is a 48-year-old healthy man
Children: 2 children, one boy, and one girl Comment by Morgan, Dorothy Tali: Are the children healthy?
Review of Systems Comment by Morgan, Dorothy Tali: You are not writing an assessment. Your review of systems should only say “Patient reports…” or “Patient denies..” then answer to each body system pertaining using the example of the Health History on Blackboard.
Review of systems
General: Overall state of health, changes in ADL’s, weight, fatigue, fever, increased infections.
Skin: Rashes, lumps, sores, itching, dryness, color change changes in hair or nails. NEUROLOGIC: Seizures, headaches, paralysis. Numbness, weakness, syncope, restless, tremors, blackouts.
Eyes: Vision, glasses, contacts, ? Last eye exam, pain, redness, excessive tearing, double vision, blurred vision, glaucoma, cataracts.
Ears: Hearing, tinnitus, vertigo, earaches, infections, discharge ? Hearing aids.
Nose and Sinuses: Frequent colds, nasal stuffing, discharge, hay fever.
Mouth and throat: Condition of gums and teeth, dentures, last exam, dry mouth, frequent sore throats hoarseness.
Neck: Lumps, “swollen glands”, goiter, pain, stiffness.
Breast: Lumps, pain, nipple discharge? Self-exam.
Respiratory: Dyspnea, SOB, pain, wheezing, crackles, orthopnea, (?) Pillows, cough, sputum (color, quantity), emphysema, bronchitis, asthma, URI, chest x-ray.
HEALTH HISTORY 7
Cardiac: Heart trouble, high blood pressure, rheumatic heart fever, murmurs, palpitations, chest pain, dyspnea. paroxysmal nocturnal dyspnea, edema, EKG, other heart test results. Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, vomiting. Frequency of bowel movements, change in pattern, rectal bleeding or black tarry stools, hemorrhoids, constipation. diarrhea. Abdominal pain, food intolerance, excessive belching or passing gas. Jaundice, liver or gallbladder trouble, hepatitis.
Urinary: Frequency, polyuria, nocturia, burning or pain on urination, hematuria, urgency, hesitancy, dribbling, UTI’s, stones.
Genital:
Male: Hernia, discharge, testicular pain or masses, history of STD’s and treatments, Sexual preference, interest, satisfaction, and problems.
Female: Age of menarche; regularity, frequency, and duration, amount of bleeding.bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension, age of menopause, menopausal symptoms, post- menopausal bleeding. If born before 1971, exposed to DES from maternal use. Discharge, itching, sores, lumps, STD’s and treatment. Number of pregnancies, deliveries, abortions, complications of pregnancy, birth control methods. Sexual preference, interest, function, satisfaction.
Peripheral vascular: Intermittent claudication, leg cramps, varicose veins, past clots. Musculoskeletal: Muscle or joint pains, stiffness, arthritis, gout, backache. Hematologic: Anemia, easy bruising or bleeding, past transfusions and any reaction. Endocrine: Thyroid trouble, heat or cold intolerance, excessive sweating, diabetes, excessive thirst or hunger, polyuria.
Psychiatric: Nervousness, tension, moods, depression, memory
General: High fever, night sweat, coughing
Skin: Reports warm, dry, and intact good turgor. Denies sores, rashes, lumps, unusual bruising, and edema
Neurologic: No seizures or memory disorder
Head: Generally round, with prominence in the frontal and occipital area (Normocephalic Comment by Morgan, Dorothy Tali: Remember you are not charting an assessment. Be sure to fix all the ones who describe an assessment
), depressions, atraumatic, no palpable masses, and scaring. However, the patient complains of dizziness but denies pain.
Eyes: Denies light sensitivity, clear conjunctiva, intact visual acuity, sclera non- icteric, PERRLA, and EOM (six cardinal gazes). No diplopia is present.
Ears: the patient denies tinnitus, sensitivity, or pain, no otorrhea present. The whisper test is standard.
Nose and Sinuses: clear nares and mucosa non-inflamed septum. No external lesions, congestion, epistaxis, or erythema present.
Mouth: Moist mucous membrane without mucosal lesions.
Gums/Teeth: full Bridge present.
Throat: No pain in swallowing nor dysphagia present.
Neck: No Stiffness and swollen glands
Breast: Normal
Respiratory: Cough and shortness of breath.
Cardiac: frequent chest pain
Gastrointestinal: Normal peristalsis, denies pain and no jaundice. Normal Tympanic sounds no hyperactive or hypoactive sounds present,
Genitourinary: the patient denies dysuria, hematuria, and nocturia frequency. She also has standard urine color, and no bleeding is present.
Genital: Female: Normal menstrual cycle
Peripheral Vascular: No vascular swellings
Musculoskeletal: Mild stage of arthritis in the right knee. The patient also complains of pain in the sacral area from past injury.
Hematologic/ lymphatic: Denies bleeding, bruising, or enlarged cervical, clavicular lymph nodes.
Neurologic: Cranial II-VII are intact; 2+, good reflexes, intact to touch, pinch and vibrations. Romberg and pronator test passed accurately.
Endocrine: the patient has polyuria, polydipsia, polyphagia, and heat and cold intolerance.
Psychiatric: the patient has depression, mental disturbance, suicidal ideas, paranoia, anxiety, and tension because of her stressful job.
Functional Assessment (Including Daily Living Activities)
Financial Status-Stable
Value-belief system- Christianity
Self-care activities – Balanced diet and regular exercises
High Self-Esteem and Self-Concept
Exercises: Morning runs
Leisure activities: Watching movies
Exercise pattern- 3 times a week
Other self-care behaviors: reduction of alcohol intake
Sleep/Rest: 8 hours of sleep daily
Nutrition/Elimination: increased carbohydrate intake
Is this menu arrangement typical of many days? -yes
Who buys meals? – the patient does it herself
Who cooks the food? – she prepares her food
Are finances enough for food? -Yes
Who is available during mealtimes? The patient and her husband
Other self-care behaviors- keeping warm at all times
Interpersonal resources/relationships
The patient’s role in the family: As a married woman, she works to contribute financially.
How does she get along with her family, friends, coworkers, and classmates? She has a good relationship with them all.
Where does she support her problem? From her husband and workmates
How much daily time does she spend alone? After work until the following morning
Is it pleasurable or isolating? – Pleasurable since she likes spending some time alone
Other self-care behaviors- Interacting with colleagues and friends to avoid loneliness
Describe stress in life now- Her diagnosis increases her stress level
Change in the past year- she was not stressed before diagnosis
Methods used to relieve stress- Interact with people and visit a psychiatrist
Are these techniques practical? – yes
Personal Habits including Daily caffeine intake such as coffee, tea, or colas
Smoking cigarettes- frequent smoker
Packet numbers per day- 1
For how long? – 12 years/daily
Age started- 23
Any prior attempt to quit smoking? What was the experience? She relapsed after two months.
Alcohol intake – On weekends.
Last date to consume alcohol – Last Saturday
Alcohol quantity taken during that episode- 3-4 wine cups
Number of days she took alcohol within the last 30 days- 3
Ever had a drinking challenge? No
Any street drug use? None
Environment/Hazards
Neighborhood and housing: Middle-class neighborhood
Area safety? Safe
Enough utilities and heat? Easy access to amenities
Involvement in community services: Weekly cleaning exercise in the neighborhood
Home or workplace hazards: N/A
Seatbelts use: Always
Residence or travel in other nations: No
Military amenity in other states: N/A
Self-care deeds: Always putting on a seatbelt while traveling from place to place
Occupational Health
Jobs held: Teacher
Satisfaction with present and past employment: Satisfied with salary and work conditions
Current place of employment: Teachers Service Commission
Please describe your job: Teaching high school students
Have you worked with any health risks? N/A
Is there equipment designed to reduce your exposure at work? N/A
Are there programs designed to observe your direction? N/A
Are there health risks that you think may relate to your job? N/A
What do you dislike or like about your profession? It pays well and has a friendly environment. Though the job is too demanding and stressful sometimes, the patient can handle it.
Perception of own health
View of own health now: Treatable
Reaction to illness: Stressed and depressed
Coping patterns/mechanisms: Taking prescribed medication
Value of health: Among the topmost life priorities
What are your worries: To quit smoking.
What are your expectations concerning your future health? To heal and get back to everyday life.
Your health goals: Improve my health by taking a balanced diet and avoiding drugs
Educational level
Grade level or highest degree attained: A Bachelor’s Degree in Education (Science)
Intellect judgment based on age Comment by Morgan, Dorothy Tali: Fill this out. You want to explain what their opinion of intellect is in regard to their age. So their own views.
Patterns of health care
Dental care: the patient visits the dentist regularly for cleaning and cavity prevention.
Preventive care: Frequent visit to the general doctor and OBGYN for annual pap smears and mammograms. Comment by Morgan, Dorothy Tali: Include time frame. When do you do their preventative care and how often?
Emergency care: Medical emergency number on patient’s speed dial.
Disease risk factors: the patient’s family history, alcohol consumption, cigarette smoking, and age increases her chances of illness.
Health promotion activities: the patient should participate in regular physical activities, maintain a fit body weight, and avoid stress and smoking. Additionally, the patient should consider changing her eating habits as the most significant health promotion strategy. Comment by Morgan, Dorothy Tali: You are missing the developmental data.
Developmental data:
Summary of developmental data and current functioning. Use Erikson’s stages of development.
Under the Eriksons stage you want to decide what stage your patient is in and write about it
NUTRITIONAL ASSESSMENT
6
17
Client’s Height _______5.9 feet________
Weight _______204.7 pounds_______________
Projected Calories:
Daily intake 2000 calories
Recommended weight
197.5 pounds
24-Hour Diet Recall;
TIME
FOOD EATEN
CALORIE AMOUNT
BREAKFAST
1 cup of Semi-skimmed milk
one mug of instant powdered coffee
Homemade date cake
42
10
66
LUNCH
Homemade steak pie served with boiled potatoes and French beans.
Orange squash
520
1.7
DINNER
Salad (Lettuce, tomatoes, beetroot, and grated cheese)
Fried fish served with vegetable rice
125
376
SNACK
one large fruit dish of sliced bananas, pineapples, watermelon, and pawpaw
one glass of water
White bread with butter
50
0
200
353
EVALUATION
FOOD CATEGORIES
SERVINGS NEEDED
SERVINGS EATEN
EVALUATION
Animal Protein
2
3
Excellent
Vegetable Protein
2
0
Poor
Dairy products calcium-rich
4
3
Fair
Whole grains, bread, and cereals
4
5
Excellent
Vitamin c-rich foods
1-2
1-2
Good
Green. Leafy vegetables
1-2
3-4
Excellent
Other fruits and vegetables
2
4
Excellent
Fats and oils
2
2
Good
Other foods
1
1
Good
Comments:
Diet Suggestions:
Increase calories _____2500______ Decrease fat ________15g______
Decrease sugar ______25g______ Increase fiber ________30g______
Increase number of meals ______3 meals____ Other _Vitamins and minerals _________
Referred to food programs
References
Jarvis, C. (2015). Physical examination and health assessment. Elsevier Health Sciences.
O’Brien, S. M., Lamanna, N., Kipps, T. J., Flinn, I., Zelenetz, A. D., Burger, J. A., … & Johnson, D. M. (2015). A phase 2 study of idelalisib plus rituximab in treatment-naive older patients with chronic lymphocytic leukemia. Blood, bslood-2015.