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Comment by Morgan, Dorothy Tali: Do not forget to include a running head to follow APA guidelines Health History Yensi Aguilar 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: 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 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 LUNCH Homemade steak pie served with boiled potatoes and French beans. Orange squash .7 DINNER Salad (Lettuce, tomatoes, beetroot, and grated cheese) Fried fish served with vegetable rice SNACK one large fruit dish of sliced bananas, pineapples, watermelon, and pawpaw one glass of water White bread with butter EVALUATION FOOD CATEGORIES SERVINGS NEEDED SERVINGS EATEN EVALUATION Animal Protein Excellent Vegetable Protein Poor Dairy products calcium-rich Fair Whole grains, bread, and cereals Excellent Vitamin c-rich foods Good Green.

Leafy vegetables Excellent Other fruits and vegetables Excellent Fats and oils Good Other foods 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.

Paper for above instructions

Running Head: HEALTH HISTORY OF L.P.
Health History
Yensi Aguilar
Benjamin Leon School of Nursing
NUR1060C: Adult Health Assessment
Professor Dorothy Morgan
April 7, 2021

Health History of Patient L.P.

Identifying Data

- Date of History: 28/02/2021
- Examiner: Yensi Aguilar
- Name: L.P.
- Address: 3403 SW 6th Street
- Phone Number: [Confidential]
- 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 discovered the hospital's address online.
- Source of History: The patient's health history documentation and discussion during the visit.
- Reliability: The patient appears mentally and physically stable.

Chief Complaints/Reasons for Visit

The patient reports a persistent high fever, blood-stained sputum, night sweats, ongoing cough, and significant weight loss.

Present Illness

- Time of Onset: Symptoms began approximately two weeks ago.
- Type of Onset: The patient initially experienced mild symptoms that progressively worsened.
- Severity: The patient rates the severity of discomfort as 5 out of 10.
- Radiation: Reports severe chest pain at night.
- Duration: Ongoing symptoms present for two weeks.
- Association: Symptoms resembling those of influenza.
- Source of Relief: Relief is experienced during rest following light activity.
- Aggravating Factors: Symptoms worsen at night and with allergen exposure.

Past Medical History

- General State of Health: Fair, managing chronic illness.
- Childhood Illnesses: Smallpox and measles.
- Adult Illnesses: Hypertension, anemia, and asthma.
- Psychiatric History: Mild depression noted.
- Surgical History: No past surgeries reported.
- Hospitalizations: Previous hospitalization at Jackson Hospital for treatment of asthma and hypertension (7 days).

Medications

- The patient takes antihypertensive medication and flu antibiotics (e.g., Azithromycin 500 mg once daily).
- Allergies: Allergic to fur and dust; reactions include sneezing and respiratory discomfort.

Family History

- Maternal/Paternal Grandparents: Died of unspecified illnesses.
- Parents: Mother with diabetes and hypertension, father deceased from cancer at age 62.
- Siblings: Healthy brother and three sisters.
- Children: Two healthy children.

Review of Systems

General: Patient reports fever, night sweats, and fatigue.
Skin: Denies rashes or unusual bruising.
Neurologic: No seizures or severe headaches reported.
Eyes: Vision intact; no recent eye problems.
Ears/Nose/Throat: No history of ear infections; throat clear with no pain during swallowing.
Respiratory: Complains of cough and shortness of breath.
Cardiac: Occasional chest pain.
Gastrointestinal: No digestive issues reported.
Genitourinary: Normal menstrual cycle; denies urinary issues.
Musculoskeletal: Mild knee arthritis; reports back pain.
Psychiatric: Experiences anxiety and tension due to work stress.

Functional Assessment

- Self-Care Activities: Balanced diet and regular exercise; seeks support from family and colleagues.
- Personal Habits: Regular caffeine and alcohol use on weekends; a long-term smoker (12 years, 1 pack per day).
- Lifestyle Changes: Attempts to quit smoking but has relapsed twice.

Environmental and Occupational Health

- Living Situation: Middle-class neighborhood, safe environment.
- Occupational Health: Works as a high school teacher; no known health risks in role, yet expresses stress from job demands.

Perception of Health

- Self-View of Health: Describes health as treatable and prioritizes health improvement strategies.

Nutritional Assessment

- Height: 5.9 feet
- Weight: 204.7 pounds
- Daily Caloric Intake: Approximately 2000 calories.
- Dietary Patterns: Intake includes balanced meals and a variety of fruits and vegetables.

Recommendations for Dietary Adjustments

1. Increase daily caloric intake to 2500 calories.
2. Decrease fat intake by 15g.
3. Reduce sugar intake by 25g.
4. Increase fiber intake to 30g per day.
5. Incorporate more vitamins and minerals into her diet.

Summary and Future Health Goals

Client L.P. should focus on maintaining regular healthcare visits, adhering strictly to prescribed medications, optimizing diet with higher nutrient density, and reducing alcohol and tobacco use. Continued monitoring of chronic conditions (hypertension, asthma) and regular check-ups are essential.

References

1. Jarvis, C. (2015). Physical Examination and Health Assessment. Elsevier Health Sciences.
2. 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, 126(scans no. 19).
3. American Psychological Association. (2020). Publication Manual of the American Psychological Association (7th ed.). American Psychological Association.
4. Centers for Disease Control and Prevention. (2021). Nutrition and the Health of Young People. Retrieved from [CDC](https://www.cdc.gov/healthyyouth/nutrition/)
5. World Health Organization. (2021). Obesity and overweight. Retrieved from [WHO](https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight)
6. National Heart, Lung, and Blood Institute. (2021). Your Guide to Lowering Blood Pressure. Retrieved from [NHLBI](https://www.nhlbi.nih.gov/health-topics/high-blood-pressure)
7. American Lung Association. (2021). Asthma and Allergies. Retrieved from [ALA](https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma)
8. Mayo Clinic. (2021). Mental Health and Stress Management. Retrieved from [Mayo Clinic](https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/mental-health/art-20046450)
9. National Institute of Health. (2021). Dietary Guidelines for Americans. Retrieved from [NIH](https://www.dietaryguidelines.gov)
10. U.S. Department of Health and Human Services. (2020). Physical Activity Guidelines for Americans. Retrieved from [HHS](https://health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines)
This comprehensive health history of patient L.P. has been gathered and structured to facilitate further medical evaluation and treatment planning.