Course Project Milestone #1: Health History Form
Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 175 points, with 5 points awarded for clarity of writing, which means the use of proper grammar, spelling, and medical language.
Type your answers on this form. Click “Save as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone1_Form_Smith”. When you are finished, submit the form to the Milestone #1 Dropbox by the deadline indicated in your guidelines. Post questions in the Q & A Forum or contact your instructor if you have questions about this assignment.
Disclaimer: The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.” BIOGRAPHICAL DATA (10 pts) | | Date: | 5/29/15 | Initials: | JS | Age: | 52 | Date of birth: | 6/1/1962 | Birthplace: | Antigua | Gender: | Female | Marital status: | Married | Race: | Black | Religion: | Christian | Occupation: | Housekeeping | Health insurance: | Carpenters Union Health Insurance through her husbands employer | Source of information: | Patient | Reliability of source of information: | Patient is responsive, alert, oriented x3, ability to recall and process information. | PRESENT HEALTH HISTORY/ILLNESS (15 pts) | | Reason for seeking care: | Routine physical, having persistent severe headaches, fluid accumulation in the right knee, and hypertension. | Health patterns: | Usually goes to the doctor once a year for a physical or when in any major pain. | Health goals: | Be pain free from headaches, stabilizing blood pressure and being able to work all day and not have knee swelling at the end of the day. | HEALTH BELIEFS AND PRACTICES (15 pts) | | Beliefs and practices: | Believe in taking herbal and natural remedies instead of having to rely on medications. | Factors influencing healthcare decisions: | Only if pain becomes unbearable or if there are physical symptoms present. | Related traits, habits or acts: | May not take medications as prescribed. Would stretch the medications for cost effective reasons and do not want to form a habit of relying on meds. | MEDICATIONS (15 pts) (Please refer to your assignment guidelines.) | | Prescription medications: | Propanolol Sustained Release 80 mg orally once a day, Aldactone 25 mg/day orally once a day. | Over-the-counter medications: | Colon Cleanse pills once a week, Nature's Bounty Odorless Garlic 1000mg 1 softgel 4 times a day. | Herbals: | Feverfew whenever patient feels a migraine | PAST HISTORY (15 pts) | | Childhood diseases: | No childhood diseases | Immunizations: | Flu, MMR, Tdap, Hepatitis | Allergies: | No known allergies | Blood transfusions: | No blood transfusions | Major illnesses: | Hypertension | Injuries: | Injury of the right knee | Hospitalizations: | Only during labor and for knee replacement surgery. | Labor and deliveries: | Cesarean section of first child, miscarriage second pregnancy of twins | Surgeries: | Total knee replacement of right knee and Cesarean section of first child. | Use of alcohol: | Drinks wine only in social settings which may be twice a month. | Use of tobacco: | Smoked a pack of cigarettes a day from age 23 to age 35. | Use of illicit drugs: | No drug use and never tried drugs in the past. | EMOTIONAL HISTORY (15 pts) | | Mental, emotional or psychiatric problems: | Mild form of depression but not clinically diagnosed from a physiatrist. Usually have a depressed feeling during menstruation. Feels alone at times since her husband works really long hours during the day and comes home and work on renovations at night. Most of their savings go into a home renovation and they do not have time to go on a vacation together and spend some much needed quality time. | FAMILY HISTORY (15 pts) | | Father: | History of hypertension, and depression from spouse’s death | Mother: | History of hypertension, diabetes, clotting and died from a heart attack | Siblings: | History or hypertension and knee injuries that causes pain | Grandparents: | Grandfather passed from cancer (form unknown) and had diabetes, grandmother had hypertension. | PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts) | | Occupational history: | History of working in maintenance, babysitting and housekeeping. | Educational level: | Middle school education | Financial background: | Used to earning a low income but when combined with husband’s income they are able to financially maintain the household. | ROLES AND RELATIONSHIPS (15 pts) | | Significant others: | Married for 9 years | Support systems: | Patient’s husband, daughter, step daughter, siblings, church family and coworkers | ETHNICITY AND CULTURE (10 pts) | | Ethnicity and culture: | Was born in Antigua where herbal remedies are widely accepted than taking medications. | Physical and social characteristics that influence healthcare decisions: | Growing up in the Caribbean where access to health care is limited and the hospitals were far from her home, most of the family only seek healthcare when there was serious problem or illness. Sometimes the symptoms were so too far developed and it was too late to reverse most of the damage. Most people did not have insurance and cash is mainly used to pay for healthcare services which most people could not afford. | SPIRITUALITY (5 pts) | | Religious and spiritual needs: | Patient is Christian and believes that through prayer that any illness can be eradicated. She also believes that maybe some of her wrongdoings in her past may have brought upon her current health problems. She will continue to pray for forgiveness so that she will not continue to have these problems. | SELF-CONCEPT (5 pts) | | View of self-worth: | Patient viewed herself in a positive way and values the way that she feels about herself. Does not need validation from her husband or another person of her worth. She finds happiness with surrounding herself with people and doing things that she loves. | Future plans: | She plans to finish renovating her home and passing it on to her daughter and her step-son so that her and husband can retired back to their home country. She also plans to travel more with her family since she feels that she missed out a lot on that due to her hectic work schedule. | REVIEW OF SYSTEMS (20 pts) (Please refer to your assignment guidelines and chapter 4 of your text. This is NOT a physical assessment.) | | Skin, hair, nails: | Varicose veins on both calves that she had surgery to remove but is self-conscious of the scars. Has pre-mature balding around the temple area and frequently dyes her hair for a more youthful look and create thickness. Nails are strong and grow fast with no discoloration. | Head, neck, related lymphatics: | Frequent migraine headaches, had tonsilar lymph node removed from neck area and when she eats it drains profusely. Feels dizziness and pressure in her head but for unknown reasons. | Eyes: | Has hyperopia, and uses over the counter reading glasses to read or see things that are close to her. | Ears, nose, mouth, and throat: | Has really bad allergies and during the spring months frequently have a runny nose, watery itchy eyes and occasional sore throat. Have fillings in mouth for over 30 years and she said they may need to be refilled. | Respiratory: | Sometimes feel a like she has shortness of breath but other than that has no respiratory issues. | Breasts and axillae: | Only does a breast examination when she has her yearly physicals. She reports there are not change in the look or shape of her breast and do not think that it is something to be concerned over. | Cardiovascular: | Has hypertension and is currently taking medications to control her blood pressure. | Peripheral vascular: | After surgery for a total knee replacement, has had major swelling at the site for due to a lack of circulation. | Abdomen: | Only mild cramping during menstruation and occasional gas pains if not eaten at least 3 meals for the day. | Urinary: | History of urinary tract infections | Reproductive: | Pre-menopausal and has light menstruation and hot flashes occasionally. Had uterine fibroids but had the removed a few years ago. | Musculoskeletal: | Has stiffness in legs after her surgery and after working a long day, has pain and stiffness in her legs. | Neurologic: | Numbness and tingling of the right quadriceps post knee surgery after standing for long hours. |