Comprehensive Health History Discussion Essay

Biographical Data:

Gender: Female                                  Marital Status: □S   □D   □M   □Sep        AGE Range: 24-35 Race/Ethnicity: African American

Occupation: Entrepreneur                                                           Employment Status: N/A

Living Arrangement: With spouse & children                               Highest Level of Formal Education: Undergraduate

Primary Language: English                                                                Communication Needs:

Authorized Representative: Spouse                                          Source of History: Interview

Travel in the past 30 days? No

Have you completed a living will/ healthcare proxy, DNR, or durable power of attorney for healthcare?

□ Yes □ No

 

Present Health History

Medication Allergy History: List all medications and supplements to which you have adverse reactions and the type of reaction. Comprehensive Health History Discussion Essay

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Food Allergy: List all foods and additives to which you have adverse reactions and the type of reaction.

None

 

Environmental Allergy:   □Dogs □Cats □Dust □Mold □Pollen(s)□Bees □Other

None

 

Current Height (ft/in) 5’5”                 Weight (lbs) 141.25lb                        Any recent weight gain or loss: slight weight gain

 

Body Mass Index: 23.5                      Weight Status Classification: Normal weight

 

 

Diet History: (?picky eater, skips meals, aversion to breakfast)

 

□Regular  □Gluten Free □Vegetarian □Diabetic □Cardiac □Renal

□Weight Reducing: type

□Other:

Number of meals per day: 3                              Number of snacks:

Amount of fluids per day: 1 liter

Caffeine Use: (what kind and how much)

 

 

Potential toxic exposures: (Lead or Radon or Mold)

□Home built before 1978:

□Occupation/ Hobby:

□ Secondhand smoke: years of exposure

□ Chemical /Electrical/Magnetic source

□Water Source (well or city)

 

 

 

 

 

 

Health Maintenance:

Total cholesterol) test date:                                                              Normal □  Abnormal □       value: 217 mg/dL

HDL                                                                                                       Normal □  Abnormal □       value: 45 mg/dL

LDL                                                                                                       Normal □  Abnormal □       value;120 mg/dL

Triglycerides                                                                                        Normal □  Abnormal □       value:165 mg/dL Colonoscopy:  test date:                                                                       Normal □  Abnormal □

TSH:  test date:                                                                                    Normal □  Abnormal □       value: 4.2 mIU/L.

Mantoux   date:                    results:

Immunizations: dates:

□Hepatitis A                                                                         □Hepatitis B __________________________

□Influenza (flu shot)                                                           □MMR  #1 _____________ #2 ____________

□Pneumovax (pneumonia)                                                □Varicella (chicken pox) shot

□Meningitis                                                                           □Tetanus (Td)  or  Tdap (tetanus & pertussis)

□Zoster

 

 

Women:                 Mammogram test date:                                     Normal □  Abnormal □

Pap Smear test date:                                           Normal □  Abnormal □

Dexa Scan (osteoporosis) test date: Normal □  Abnormal □

 

Men:                      PSA (prostate) test date:                                    Normal □  Abnormal □

 

                                                                                                                                                                                                               

Personal Health Habits:

Cigarette   Smoking:         □Past Quit Date:                  □Current: pack/years

 

Other Tobacco: □Pipe □Cigar □Snuff □Chew □Vaping

 

Are you interested in quitting? □No □Yes □NA

Have you tried any smoking cessation products?

 

Alcohol use:

Has anyone ever told you that you drink too much or that you should quit?

Is anyone in your family an alcoholic? Yes, my brother

How does drinking alcohol affect your life?

 

Drug Use:

Do you use any recreational drugs?  □No □Yes

Recreational or Addictive drugs used:

Has anyone ever told you that you should stop using drugs?

Has anyone in your family used/used drugs?

How does using drugs affect your life? Comprehensive Health History Discussion Essay

 

How often do you exercise: 30 minutes a day

What kind of exercise do you do? Walk

If you do not exercise, why?

 

Safety:  

Do you use a bike helmet? □No □Yes □NA     Do you use seatbelts consistently? □No □Yes

Do you have a smoke alarm in your home? □No □Yes Carbon Monoxide? □No □Yes

Do you have a gun in your home? □No □Yes. How is it stored?

 

Sleep Patterns:

Usual hours of sleep: 7 hours                                           Quality:  good

Naps:  □ No □ Yes frequency: Daily                               Duration: 30 minutes

Sleep aids: No

Do you snore? No

 

Self-Breast exam:

Self -Testicular exam:

 

Violence Screen:

Because violence is so common in many people’s lives, I’ve begun to ask all my patients about it:

 

Do you feel controlled or isolated by your partner?                                                     □ Yes    □ No

Do you ever feel afraid of your partner?                                                                         □ Yes    □ No

Do you feel you are in danger? Is it safe for you to go home?                                   □ Yes    □ No

Has your partner ever forced you to have sex when you didn’t want to? □ Yes    □ No

Has your partner ever refused to practice safe sex?                                                      □ Yes    □ No

Are you in a relationship with a person who physically hurts or threatens you?  □ Yes    □ No

Has your partner ever threatened to hurt you or someone close to you?   □ Yes    □ No

Have you ever been hit, kicked, slapped, pushed, or shoved by your boyfriend/husband/partner? □ Yes    □ No

 

Family History:  Please indicate sibling (male, female); parent (mother/father), grandparent (maternal/paternal)

 

Allergies: none                                                    Hypertension: Mother

Renal Disease: Paternal grandmother            CAD/CHF: None

Diabetes: Paternal grandmother                      Stroke: Maternal Grandfather

Peripheral Vascular Disease; none           Cancer: Paternal aunt

Respiratory Illness: Asthma/ COPD; none   GI Disorders: IBS: None

Diverticulitis: None                         Colitis: none

GERD: none                                Neuromuscular Disorders: Acute/Degenerative: None

Autoimmune: None

Genetic Disorders: None                                    Mental Illness: Alcoholism

Alcohol /Drug Abuse: Brother/Paternal Uncle

Abuse: None

Surgical History: None

Other than childbirth – Has any family member been hospitalized for a surgical procedure? Yes, Mother for hysterectomy.

 

Social/Cultural:

Where did your family live when you were growing up? In Seattle

Country of Origin? The United States

What were the occupations of your parents? My father was a doctor, and my mother was a nurse.  Comprehensive Health History Discussion Essay

What grade in school did your parents complete? Undergraduate programs

Spiritual Resources/Religion? Christian

Any Health Beliefs/Health Perceptions. I believe that health and disease can be altered through diet. I have seen many friends, acquaintances, and social media influencers turn their health conditions around by diet alone. I believe it is essential to identify reliable sources of information and apply the knowledge consistently to see results.

 

 

Personal History:

Current Concerns: Fatigue and headache

Reason for today’s exam:

 

Mental:   □Fatigue   □Nervousness    □Anxiety    □Irritability / Anger     □Depression    □Inability to focus / concentrate □Stress □Other

Describe if any of the above are checked.

I feel constant fatigue even when I rest over the weekend and sleep for 7 hours daily. The quality of my sleep is good because I fall asleep fast and rarely wake up in the middle of the night.

I have been feeling irritable lately, and I feel intense anger whenever I feel inconvenienced. I experience bouts of road rage whenever other drivers are inconsiderate, and I curse them out.

Physical: □New or Worsening Pain □Headache(s) □ Changes in appetite □Change in Bowel or Bladder function □Palpitations □ Skin changes □ Other

Describe if any of the above are checked.

I have been feeling a throbbing headache at the temples of my head. The headache does not go away even after taking pain medications. It has affected the quality of my life because I no longer feel motivated to go out or do anything other than the necessary activities.

I have been feeling hungrier than usual over the past few months. I have managed my hunger by avoiding sugar, drinking lots of water, and reducing carbohydrate consumption. I have increased my protein consumption. However, I still feel hungry and thirsty even after taking water. I have also started to notice an increased frequency of urination.

 

Medical History to date:

 

1. Pre-eclampsia-diagnosed four years ago during the first pregnancy

A history of pre-eclampsia is a significant risk factor for the development of hypertension.

 

Surgical History to date:

 

1. Birth via cesarean section four years ago

 

Psychological Wellbeing:

Self-Esteem, Self-Concept: (include education, roles, financial concerns, values, beliefs, perceptions of personal strengths, self-care behaviors)

 

My psychological wellbeing is a continuous journey because I keep learning and growing daily. I have high self-esteem whenever I accomplish my goals and become my best self. I can have low self-esteem during periods of failure and conflict with others. However, I am learning to extend grace to myself and forgive my mistakes. Comprehensive Health History Discussion Essay

I am reasonably successful in my education career and family life as I have completed an undergraduate program and run a successful clothing business in the heart of Washington, DC. I am proud of what my parents’ resources have achieved for me.

I also have a successful marriage. I have been married for five years, and my partner and I remain committed to each other regardless of life’s challenges. I am confident that we shall give our present and children the family they deserve and support them through their developmental stages.

Interpersonal relationships: (roles, social contacts, support systems, self-time, stressors, satisfaction level)

I have excellent interpersonal relationships with colleagues and friends. I try to be there for my close friends and relatives and create a sense of family. My mother and husband are my most outstanding support system. They help me navigate life’s challenges, especially motherhood, business, and family. I recognize the importance of taking time to do the things I love to rejuvenate my spirit. I have found that alone time is critical to keeping me grounded and balanced.    

Coping and Stress management: (Stressors, now, in the past, stress relief measures)

 

Beyond self-care, spirituality has been instrumental in helping me manage stress because I take all my burdens and cares to God. Everything that I feel is beyond my ability as a human being, so I take it to God and pray that he comes through for me. Once I let go of everything beyond my control, I focus on those within my control.

Perception of own Health:

I have been feeling ill since four years ago, and I would like to turn that around using all the resources available to me

View of your health and its importance

 

My health is imperative to my overall wellbeing, quality of life, and functionality.

 

 Future goals and expectations

 

I am committed to collaborating with health professionals and other providers to improve my health.

 

Occupational Health:

Describe the job: Shop sales

Potential hazards or hazardous environment: none

Repetitive activity: scanning items, hanging and unhanging clothes

Problems related to the job: none

How do you feel about your job? I feel fulfilled because I am passionate about helping people look competent and confident.

 

Review of Systems:

General Health: Reports weight gain, fatigue and weakness

Skin, Hair, Nails: Denies changes in skin appearance.

Head: Confirms headache

Eyes: Confirms blurred vision

Ears: Denies hearing loss, tinnitus, discharge, or pain

Nose, Mouth, and Throat: Denies nasal congestion, discharge, or pain. Denies mouth sores, pain, or swallowing difficulties. Denies pain in the neck, and the physical examination identified no swelling.

Breasts: Physical examination identified no lumps or discharge. The patient denies skin sensitivity.

Respiratory System: Denies dyspnea, pain, coughing, sneezing or wheezing.

Cardiovascular System: Denies syncope, angina, tachycardia, arrhythmias, bradycardia, or edema.

Peripheral Vascular System: denies numbness, pain, tingling, cramping, temperature changes, ulceration, or edema in the peripheries.

Gastrointestinal System: Confirms increased appetite. Denies abdominal pain, nausea, vomiting, and discomfort. Comprehensive Health History Discussion Essay

Urinary System: Confirms polyuria. Denies pain, incontinence, and blood in urine

Male Genital System: N/A

Female Genital System: Denies pelvic pain. Confirms regular menstrual cycle.

Musculoskeletal System: Denies joint and back pain.

Neurologic System: Denies tingling and loss of sensitivity

Hematologic system: Confirms fatigue. Denies easy bruising. Physical examination did not identify any swollen lymph nodes.

Endocrine System: Denies heat waves, night sweats, difficulty sleeping and vaginal dryness. The patient confirms mood changes and irritability.

Student Reflection:

Following the symptom presentation, the patient appears to be diabetic or pre-diabetic. Although the patient has a normal weight and undertakes physical exercise regularly, they still have an imbalanced cholesterol profile and early diabetes symptoms. The patient seems aware of the health risks of consuming unhealthy diets consisting of highly processed foods and added sugars. Although she has already made some of the dietary changes required to change her health status, she still requires the guidance and support of a health professional to manage the condition. The patient has done well visiting the health facility early to allow the application of an intervention before the disease progresses, causes complications, and worsens the prognosis.    Comprehensive Health History Discussion Essay

 

 

 

 

Medication List
Current Medications Including herbal supplements, vitamins, etc., and date started	Indications	Effectiveness: Works? Doesn’t Work? Side Effects? Compliance with the schedule?	Client Concerns
Paracetamol	Headaches	Does not work	The client feels that an underlying issue might cause the headaches

Medication Failures:

 

The painkillers did not work because the headache was caused by an underlying issue, most notably elevated blood glucose (Haghighi et al., 2016). The best way to manage this symptom is to administer metformin to control the blood glucose levels.

 

Area of Health Concern/Health Promotion based on Identified Strengths:

 

The patient should increase the frequency and intensity of physical exercise to reduce insulin resistance and control blood glucose levels (Bird & Hawley, 2016).

 

The patient has already started taking the appropriate steps towards recovery by halting sugar consumption. Comprehensive Health History Discussion Essay

 

Recommended Referrals:

 

The patient shall revisit the health facility for review after two weeks.

They shall be referred to an endocrinologist depending on their response to the medication.

 

Referral to a nutritionist is recommended to support the patient in making dietary changes.

 

 

Health Education Plan:

The health professional shall explain the nature of the condition to the patient and the importance of adhering to the medications.

The health professional shall provide web resources and journal articles on emerging research.  Comprehensive Health History Discussion Essay

 

Complete MNA:

 

Appetite Loss: increased food consumption

Weight Loss: weight gain in the past few months

Mobility: Able to move around unassisted

Acute Disease: None

Psychological Distress: None

Dietary Assessment: 3 meals daily, adequate fluid intake, the patient feeds unassisted.

Global Assessment: The patient lives independently, has no pressure ulcers, and takes pain medications.

Subjective Assessment: The patient feels their health is suboptimal but feels confident in her ability to improve it.

Interpretation of Nutritional Status: Normal

Recommendations: Continue with diet and increase physical activity.  Comprehensive Health History Discussion Essay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature:

References

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Bird, S. R., & Hawley, J. A. (2016). Update on the effects of physical activity on insulin sensitivity in humans. BMJ Open Sport — Exercise Medicine, 2(1). https://doi.org/10.1136/bmjsem-2016-000143

Haghighi, F. S., Rahmanian, M., Namiranian, N., Arzaghi, S. M., Dehghan, F., Chavoshzade, F., & Sepehri, F. (2016). Migraine and type 2 diabetes: is there any association? Journal of Diabetes and Metabolic Disorders, 15. https://doi.org/10.1186/s40200-016-0241-y

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During this Lab Experience students will meet objectives by (1) obtaining a health assessment on an acquaintance, using the comprehensive health assessment form.

Begin working on health history
Describe nursing interventions that will assist with health
Identify health promotion behaviors
Comprehensive Health Assessment

Identify a family member or friend to act as your standardized patient
When communicating with your participant. Read the Standardized Participant (SP) form prior to beginning the assignment.
Alert the Standardized Participant that they don’t have to reveal everything and they also can embellish or withhold. This is an academic exercise only. If they grant consent, put the name of the participant in the appropriate place and type your name as by proxy.
Use the comprehensive health assessment/health promotion worksheet to complete the assignment
Review health history videos. Comprehensive Health History Discussion Essay