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Module 03 Written Assignment Comprehensive Health History

Module 03 Written Assignment Comprehensive Health History

Sample Answer 

Module 03 Content

Your comprehensive health history that was assigned in Module 01 is now due. Complete a comprehensive history, utilizing the form linked below, on either someone over the age of 65 or someone that you know has a lot of medical problems.

Write the results in narrative format and include the family history as a genogram (see your text).

Visit the following link for help with narrative format: http://rasmussen.libanswers.com/faq/32455

Completed Example: Module 03 Written Assignment Comprehensive Health Assessment

Health History

Biographical Data

The patient is a 64-year-old female, married with three children. Her DOB is June 3rd, 1956. The patient highest education completed was high school and currently works as a teacher’s assistant. The ethnicity is of Asian descent. She was born in Guyana and migrated to the United States at the age of 18. The patient herself provided the source of information gathered in this comprehensive health assessment.

Present Health History

The patient current medical condition includes a left knee and ankle pain due to an accidental fall in the snow, which occurred in January of 2019. The patient is only taking one a day multivitamin supplements and ibuprofen 500 Mg as needed for pain. She has no allergies to food or medication, .and denies any latex or contact allergies.

Past Health History

The Patient past medical history includes having chickenpox at the age of 18. The patient denies any childhood illness that she can recall. In 2011 the patient contracted a severe case of pneumonia in which she was hospitalized for five days. She was able to make a full recovery since then with no complications or effects from the illness. The patient denies any other hospitalization or surgeries. In the birth of all 3 of her children did, however, required a cesarian section for each successful pregnancy. In January of 2019, the patient had a slip and fall accident due to snow on the ground, which resulted in a sprain to the left ankle and a small tear to the left knee. The patient’s treatment included ten weeks of physical therapy, which she completed successfully. The patient denies any past illness other than the occasional cold and flu.

Immunizations

The patient is unsure of any vaccinations she may have received in her native country or the United States. She stated she only gets regular influenza shots every year. The last influenza shot she received was last year, December of 2019. The patient further confirmed she has not traveled within the past year.

Dated of the Last Examination

The patient regularly goes to her primary care provider for annual follow-ups that include a full physical examination, dental and vision care. Her last complete physical, dental, and vision examination was completed in September of 2019. The patient also had recently followed up visits for MRI and X-Rays on the left knee due to the accident in January of 2019 (Please refer to Present Health History Section).

Family History (Genotype)

Please refer to the attached Genogram for patient family history record.

Module 03 Written Assignment Comprehensive Health History

Module 03 Written Assignment Comprehensive Health History

Review of the Systems

The patient stated she has not been sleeping well since her accident in January 2019. She stated that she would have pain and numbness she believed to be associated with the accident mostly at night or extensive periods of inactivity. The pain usually occurs in the left knee and radiates at times to her toes, which can get numb. She stated her pain scale at its highest point would be a seven, and the lowest would be a 4 or 5. She denies any other issues and has not had an associated sign or symptoms other than the ones listed above.

Integumentary

The patient has no abnormalities or changes to her skin color or texture; she further denies any changes to moles that may trigger a concern. The patient stated that she does not have any burns, skin lesions, or sores. The patient stated she had not noticed any changes to her hair or nails; she further denies any splitting or cracking or texture changes.

HEENT

The patient denies headaches, head injury or trauma, no history of concussions, dizziness, or loss of consciousness. The patient also denies having stiffness in the neck or pain. She denies any enlargement to lymph nodes, swelling, or mass in the neck. She has no difficulty in swallowing or notice any other distress in the area. In regards to her vision, the patient uses prescription corrective lense (glasses) only for reading. She has no further vision impairment and believes the decrease in vision is associated with aging.

Furthermore, the patient denies any light sensitivity, discharges, or pain. The patient has not had an ear test completed. The patient stated she did have some ringing in the ears about two months ago. However, it has only lasted for a short period and did not see it as a problem or an alarming event. She further stated she did not follow with medical care as the symptoms subsided quickly (lasting less than a day and never occurred since). The patient further denies that she has not had any other issues or changes to her hearing. She further denies any vertigo, ear infections, or excessive wax problems. The patient does not require a hearing aid. The patient denies any nasal or sinus issues; She does not have any nosebleeds, nasal obstructions, snoring, postnasal drips (other than the ones usually occurring when she has a cold or flu). The patient does not have any allergies or use recreational drugs.

Regarding the mouth/ oropharynx, the patient does not have a sore throat, mouth sores, bleeding gums hoarseness, or change in voice quality. The patient further denies difficulty swallowing, chewing, or change ins taste. The patient does not wear any dentures or bridges.

Respiratory

The patient denies any respiratory symptoms such as colds, pains with breathing, coughing up blood, wheezing, night sweats, or other respiratory distress. The patient stated in 2011 she had an x-ray completed as part of her recommended treatment plan following her contracting pneumonia; she has not had any issues or reasons to obtain another one since then, As part of her employment requirement she receives PPD follow up every 3-5 years. She further stated she had not had any positive results from any of her tests. The patient denies ever smoking or contact with secondary smoke.

Cardiovascular

The patient denies chest pains, palpitation, shortness of breath, edema, coldness or extremities, color changes, hands, feet, hair loss on legs, or leg pain with activity. The patient denies any paresthesia, or sores that do not heal. The patient received a complete physical in September of 2019. She had an EKG performed as part of the exam, and the results showed no abnormalities.

Breasts

The patient denies concerning changes, masses, discharges, or changes in appearance; The patient confirmed in 2015, she had a biopsy performed on her right breast due to a developed mass. The result was benign cysts and has not been a concern. As part of the patient’s yearly physicals, she gets annual mammograms done. She also performs her self tests regularly.

Gastrointestinal

The patient has not had any changes in appetite, The patient denies any gastroesophageal reflux disease, pain, nausea/vomiting, vomiting blood, jaundice, changes in bowel habits, diarrhea, constipation, flatus, The patient has not had any fecal blood test or colonoscopy or other gastro related testing or procedures.

Genitourinary and Reproductive

The patient denies pain or burning in urination; The patient stated she had not noticed any changes in genitourinary other than frequency to urine more at night. She further associates these symptoms with the normal aging process and changes occurring due to post-menopause. The patient has not reported the symptoms to her physician as she feels there is no need. The patient stated she notices these changes occurring shortly after menopause. The patient denies incontinence or inability to control her urges. She further denies any other symptoms. The patient is currently in the postmenopausal stage since the age of 57. She occasionally experiences hot flashes but has these symptoms less frequent with aging. The patient also experienced two miscarriages in her mid 30’s after 12 years from the birth of her first child. The patient has only had one sexual partner all her life.

Musculoskeletal

The patient denies any past fractures. The patient stated that due to the recent left ankle and knee injury in 2019, she had experienced some pain as outlined above. The patient stated that she would also have stiffness and swelling during periods of inactivity or weather changes. The patient denies any limitations of mobility. The patient denies back pain, loss of height, or sensations. The patient stated that due to the injury, she notices her gait may be a little off as she seems to distribute more of the weight on her right leg than her left. She denies it is due to discomfort or pain or other stressors. She stated it is something She recently started doing as of late. The patient has had several X-rays and MRIs to the left knee and ankle as part of her ongoing therapy care plan and post-follow-ups. These tests confirm a left ankle sprain with tear to the meniscus of the left knee. The patient stated that she did not need surgery or had any procedures done. She stated she was in a boot for a few weeks and since she does not require any mobility aids or assistance walking or performing daily activities. She further stated that the injury had not limited her abilities in performing daily activities.

Neurological

The patient denies any pain, fainting, seizures, changes in cognition, or memory. The patient does experience numbness at night or is not active long to the left foot and ankle, as outlined in previous sections of this report. The patient denies any further neurological systems and associated the numbness she is feeling with her injury. The patient denies any problems with coordination, tremors, or spasms.

Psychosocial Profile

The patient stated that she tries to maintain her health by walking at least 20-30 minutes daily. The patient stated she could keep up with her walks, and the injury does not impede her ability to upkeep her routine. The patient does not exercise but is looking to include yoga or other low impact workouts to her schedule. The only self-examination the patient performs is post-shower, looking over the body and self-breast checks. The patient has routine dental checkups and brushes twice a day and flosses with each brushing. The patient has routine yearly physicals and performs self blood pressure and glucose checkups at home using an automatic blood pressure machine, and glucose monitor weekly.

Nutritional Pattern

The patient stated she tries her best to maintain healthy eating and implement a daily serving of vegetables, grains, and fruits to her diet. The patient stated she also limits her intake of sugar, animal protein, and animal fats as much as she can.

24 Recall

The patient had breakfast at 7 AM consisting of egg whites, a slice of whole-wheat toast, coffee, and a patient, snacked at 10 AM on watermelon slices. The patient stated she drank several cups of water in between and did not have another meal until dinner time at 6 PM. Dinner consists of brown Rice with grill salmon and sauteed spinach. The patient has a small cup of sugar-free ice cream at 9 PM and does not have another meal until 8 AM. The following day, the patient has a yogurt (cup) with berries and almonds and a coffee cup for breakfast. The patient’s next meal is at lunch, which occurred at 2 PM. It consisted of several slices of low sodium deli turkey on lettuce and whole-wheat toast and 16 oz water. The patient stated that her next meal was at dinner at 7 PM of grill chicken breast and sauteed vegetables with water. The patient stated she did not have another meal until the next day at breakfast again. The patient stated she usually eats when she is hungry, and food is always available.

Functional Ability

The patient denies any inability to perform her daily tasks or activities. She further states she can dress, eat, toilet without aid. The patient stated she does not drive because of choice. However, she enjoys going out shopping, cooking, and gardening.

Sleep/rest patterns & Personal habits (tobacco, alcohol, caffeine, and drugs)

The patient stated that due to the numbness and pain in the left ankle, she has not been able to sleep throughout the night. She also stated that she noticed she was feeling irritable due to the lack of sleep but has been getting help from meditation sessions performed before going to bed. It has helped with both the symptoms and sleep patterns. The patient does not take naps. The patient stated she tries to average a minimum of 8 hours of sleep, but her injury has been averaging 5 hours. The patient’s habits include having a serving of coffee every morning and. She denies tobacco, alcohol, or drug use.

Environmental history & Family/social relationships

The patient lives in her own home in a rural area of New Jersey. The patient currently lives with her spouse and two adult children. She has a strong working relationship with her husband of 33 years and stated she is pleased with her home life and relationship with her spouse.

Cultural/religious influences & Mental Health

The patient considers herself a devoted Hindu and follows religious practices daily. She is also very involved in cultural events in her community and teaching the youth. She believes strongly in passing down her cultural practices to children. Her cultural beliefs influence her daily living and overall health. Believing in a higher form (god) helps with coping with unexpected stresses that may occur in life. Her religion limits her to eat meat and animal products. She maintains fasting once a week of only eating meals consisting of fresh vegetables, fruits, and grains. The patient stated she meditates daily for 1hour, and it has helped her immensely in dealing with stressors or events; she further confirms that her mental wellness is in part due to religious and personal practices. The patient denies any anxiety or feeling of depression. The irritability, due to the absence of sleep, has improved significantly since adding a meditation session at night before she goes to bed. She admits that due to the recent pandemic, she has not been able to participate in community events and feels that this has also led to her irritability.

Strengths and Weaknesses

In reviewing the subjective data, the patient’s strengths lie in her coping mechanism through her cultural-religious belief systems and a reliable family support system. Her religious practices allow her to deal with stressful events and overcome any mental barriers. Her daily meditative practice has allowed her to cope with the stress of pain and numbness at night associated with her injury and deal with irritability from the change in her sleeping pattern and world events. Her marriage of 33 years reveals a strong relationship with her spouse, and family bond is further supporting evidence that she has a strong base that she can turn too in times of stress.

In discovering areas of weaknesses, The patient lack a routine eating habit, and her attitude on eating when she is hungry is one that stands out. In addition, the unusual change in her gait brings about an area of concern that her ankle and knee injury has not fully healed and that she may be in an allostatic position in which her body may be showing subtle signs in coping with the stressor. Her attitude regarding some of her symptoms resulting from the usual aging process brings about another concern that she may be ignoring severe conditions in her body.

References

Jarvis. C. (2020). Physical Examination & Health Assessment (8th ed, pp.44 -54) Elsevier.

Comprehensive Health History Form

Comprehensive Health History Assignment

 

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