Health History
Examiner: Melissa Paulino
Demographics
My patient is J.M. is a 24 years-old Caucasian female. She was born and raised in Spotswood, New Jersey. She is catholic, but does not practice her religion or attend church. She is currently in a relationship with a female and has no children. She has a Bachelor’s degree in Health Studies from Monmouth University and is currently obtaining her master’s degree in Healthcare Administration at Felician University. She works at an office as a benefits coordinator, but is seeking for a position in management at a hospital. She is an only child and is living at home with her parents. She has plenty of friends and family that she remains in close contact with. She claims to feel bothered and stressed because she is not comfortable with her hour commute to work and her work environment. She seems to be stressed and emotional about not being able to spend time with her significant other because they are both very busy with school and work. She does not feel like she has enough time to prepare meals which leaves her to eating fast food sometimes, but enjoys eating healthy foods. Her parents do not cook things that she likes or that are healthy
Health Perception
The patient states, “Being in sound, mental, physical, emotional condition”. Patients believes to be in good health and plans to stay that way.
Past Medical History
Immunization/Vaccines: Patient is up to date with all of her immunizations/vaccines except for the Influenza vaccines; Hep A, Hep B, MMR, Polio, Tetanus, DTap, Varicella, Pertussis, Diphtheria, and Hib.
Diseases/Disorders: Patient is currently free of diseases and disorders.
Medications: Allergy medications, multivitamin daily, 500 mg of calcium daily, Vitamin B12 daily, Advil as needed, and birth control.
Surgeries: No major surgeries in the past, except for oral surgery to remove all her wisdom teeth at age 18.
Accidents/Injuries: Minor ankle sprain in 2016.
Smoking/Alcohol: Patient does not smoke. Patient says she is a “social drinker” and drinks moderately.
Family History
Paternal Grandfather; P.M.
Patient states that her paternal Grandfather was born on 1932 and passed away in 2011. He worked as a Government Worker and obtained his Bachelor’s Degree in Business. His primary language is English. She states that he had a heart attack at 42, but was always generally healthy until developed myelodysplastic syndrome later in life, which eventually killed him.
Paternal Grandmother; M.M
Patient states her paternal grandmother’s birthdate was on 1933 and is currently alive. She was a nurse and obtained a B.S. in nursing. Patient states that she is very healthy, has fallen multiple times and broken her hip and knee twice, and is developing dementia. Patient states that she smokes cigarettes.
Father; W.M.
Patient states that her father was born on 1959 and is still alive. She states that he is a retired electrical worker. When to some college and primary language is English. She states that he has “stomach issues, high anxiety, and problematic health”. Patient states that he has one sibling that is “somewhat healthy, smokes cigarettes and deals with stress on the daily basis.” The patients adds that her father’s brother takes care of their mother , “which can be the source of his stress”.
Maternal Grandfather; G.C.
Patient states that her maternal grandfather was born in 1922 and passed away 1986. He worked as a Welder and only obtained a high school degree. His primary language is English. Patient states that he was in good health and died of melanoma.
Maternal Grandmother; G.C.
Patient states that maternal grandmother was born in 1928 and passed away 2004. She was a Senior Citizen Director and obtained a degree at some college. Her primary language was English. Patient states that she suffered with lupus throughout her life and died of sepsis.
Mother; P.M.
Patient states that her mother was born in 1958 and is alive. She works as an administrative assistant and went to business school. Her primary language is English. Patient also states that “she is healthy and was diagnosed and beat early stage Ovarian Cancer and has sinus issues who life.” Patient states that her mother’s sibling suffered from Lupus, diabetes, stroke, and appendix burst.
Adult Participant: J.M.
Patient states that she was born in 1992 and is a benefits coordinator. She states that she has a B.S. in Health Studies and is pursing M.S. in Healthcare Administration. Her primary language is English. She states that she is healthy, tries to ear right, exercises regularly, does not smoke or do drugs, and maintains a healthy lifestyle. She states that she is an only child.
Adult Participant’s significant other:
Patient states that her significant other was born on 1993. She is a patient care assistant and is currently going to nursing school. Her primary language is English. She also can speak Spanish fluently. Patient states that her significant other is in very good health with healthy habits. Patient states that her significant other is dealing with irregular periods and is suspected to have polycystic ovary syndrome. Patients adds that they do not have any children together, do not live together, and are not married.
Review of Systems
General Appearance
Patients appearance seems normal and good. Patient is oriented to self, time, and place. Patient has good posture. There are no obvious physical deformities present. Dressed appropriate for the weather. Facial features are appropriate to the situation. No visible devices and equipment present. Patient seems to be calm and relaxed. There is no signs of distress. Mood and effect is appropriate.
Skin, hair, and nails
The patient’s skin is fair complexion. Dry and warm to touch. . She has good skin turgor and skin’s temperature is within normal limit. The skin color is appropriate for age and ethnicity. No lesions, rashes, or wounds. Patients nails are smooth and intact. Patients nails are clean and convex. Clean and cut fingernails. Capillary refill less than two seconds. No tattoos. Patients hair is clean and evenly distributed. Color of the hair is light brown thick, silky hair. No masses, no tenderness, and no knits.
Head, neck, and lymphatics
Patients head is normocephalic and symmetrical. Patients skull has no masses, no wounds, no nodules and depressions noted. Patients states,” I do not feel any pain on my head when you touch it.” No piercings or tattoos present. Patients face has symmetrical movements. Patients lymph nodes were palpated. Patient stated no pain when preauricular, posterior auricular, occipital, submental, submandibular, jugulodigastric were palpated. Neck is positioned midline without tenderness and flexes easily. No masses palpated. Thyroid gland is not visible on inspection. Head movement is coordinated and patient states no discomfort or pain when head is laterally flexed, head laterally rotates and hyperextends. When assessing the neck, I palpated the cervical lymph nodes, superficial, posterior, and deep. Patient states, “I do not feel pain or tenderness.”. I palpated the patients supraclavicular and no pain or tenderness was noted.
Eyes
Patients eye lashes are evenly distributed. Skin on eyelids are intact with no discharge or discoloration. Lids close symmetrically and blink involuntary. Patients eyebrows hair is evenly distributed. Eye brows are symmetrical and show equal movement. Patients sclera are white. Conjunctiva is shiny and pink. Pupils are black, reactive to light, equal size, round and respond to accommodation.
Ears, nose, mouth, and throat
Voice sound audible. No discharge or redness noted. Nose appear symmetric, straight and uniform in color. No discharge or flaring in nose. When nose was palpated, there were no tenderness and lesions. Nasal septum intact and mucosa is pink with no lesions. Bilateral patency was tested by the patient covering one nostril and inhaling, this was done on both side. Patient states, “I have no problem breathing.” Nares are patent with no drainage or discharge. Mouth is symmetrical, pale lips, brown gums and able to purse lips. Patient gums are pink with no lesions or cracking. Teeth are white and straight. Tongue is in central position and pink. When palpated, tongue movement is without difficult and without tenderness. Uvula is positioned midline of soft palate.
Respiratory
Patients chest is symmetrical. Breath sounds are normal without dyspnea. Quiet and effortless respirations. No signs of scoliosis, kyphosis, or lordosis. No masses or tenderness in chest wall. Patient has symmetric expansion. Upon feeling for tactile fremitus and asked patient to say “99” normal vibrations intensities felt. Auscultated and palpated anterior and posterior lung fields. Normal breath sounds are heard and no masses or tenderness noted. No pulsations on the aortic and pulmonic areas.
Breasts and Axillary
No tenderness or lesions in breasts. When palpated, no masses or nodules notes. When axillae was palpated there was no tenderness on axillary nodes.
Cardiovascular
Patient states that she never suffered from any heart issue. No palpitations in the heart. Patient stays away from coffee. She states that she never had chest pains. She is very athletic. She has done sports all her life. She states, “I think my heart is the strongest muscle in my body.” She states that she has a very good endurance. She currently plays football.
Peripheral
Patient feels like she has good circulation. Patient is very active. Never had any swelling in her body. Patient states that sexually activity is normal for her. Patient reported that she has felt tingling and numbness when she sits down for too long or texts on her phone in a laying position, but circulation returns right away. Numbness and tingling is not frequent.
Abdomen
No distension in abdomen noted. Patients states no tenderness or discomfort while palpating abdomen. Patient skin is the same as the rest of her body. No bruises or burns noted. Normal bowel sounds. Patient has a bowel movement 2-3 times a day. Patient states that she digests food properly, no acid reflex, or hurt burn occurs. Patient states having a normal appetite.
Urinary
Patient states that she urinates regularly. She makes sure to drink plenty of water to stay hydrated. She never feels any burning sensations when she urinates. Patient has no itching, no burning, no tenderness, or foul odor.
Reproductive
Patient never had a child. She is sexually active with a woman that she is in a committed relationship with. Patient states that they never used any form of contraception. Patient states that she takes birth control to avoid the risk of cervical cancer like her mother once had. Patient never has an STD. Patient has been sexually active with 4 people in her life time. Patient does not expect to pregnant anytime soon. Patient states that she does want children someday.
Musculoskeletal
Muscle strength is equal strength bilaterally. Patient is able to walk straight and move limbs appropriately. No sign of discomfort. Patient makes sure to take calcium as a vitamin. She eats and drink dairy products. Patient enjoy walking outside when the sun is out so she can get vitamin D exposure. Patient has never broken any bones in her body.
Neurologic
Patient states to be sane. Patient has no experienced any traumatic or threatening events. Patient is able to function properly and manages to take care of herself. She states that she makes sure to exercise because that makes her feel like “a new woman and it makes her happy.” Patient seems to be aware of herself.
Developmental Considerations
Patient is not cognitive delayed. She is aware of her duties as an adult. She maintains a balanced life when it comes work, school, making time for her health, relationships with family, friends, and significant other. She is capable of furthering her education. She believes that she has not suffered any traumatic events in her life. Patient states “Apart from not being in the career I want to be in, I have a happy and comfortable life so far.” After talking to her she seems self-aware and has emotional intelligence.
Cultural Considerations
Patient was born and raised in America. She has no specific traditions except for celebrating Christmas and Thanksgiving. There is no culturally preferred food. Patients family and her eat anything they are in the mood for that day.
Psychosocial Considerations
During my assessment, patient appears to have good hygiene, wearing proper clothing for the weather and gender. Patient has good posture. She is awake, alert, and oriented. At the time being, nonverbal cues seem appropriate to what is being said. Patient does not seem to be in any type of distress. She is relaxed, comfortable, and cooperative. She seems to be very self-aware and confident.
For this patient, I would make the reproductive system the priority in my physical assessment. After collecting the patients’ health history, past history, and family history, the patient is a healthy young adult and lives a healthy lifestyle. However, her mother suffered from ovarian cancer at age 35, which puts her at higher risk for ovarian cancer, as well. I would make sure that she is informed of the risk factors and prevention of ovarian cancer.
I will teach the patient basic nutrition education so that the patient has an understanding of foods that are healthier, foods that provide the most energy, foods that will fill her up faster, and easy, quick healthy meals to prepare at home. Also, I will inform the patient about stress reduction techniques so that her daily responsibilities won’t become too overwhelming.
Collaborative Resources
The patient and I discussed a plan to improve her diet by cutting back on fast food and spending money in restaurants. Also, it is important for the patient to find another job if the commute is too long for her. This seems to be a major stressor for her at the moment. She agreed to continue applying to jobs that are closer to her home. We discussed about coping mechanism for when she is stressed. I encouraged her to continue exercising because that will relieve a lot of her stress. I also encouraged her to do breathing techniques, yoga, painting, coloring, reading, journaling, or time management. I encouraged about the importance of taking care of herself and making time for herself, which means doing the things she loves as an individual. Patient and I discussed about communicating effectively with significant other so that they can agree on spending time together more often. Patient suggested a date night twice a month which will make her feel more at ease. We also discussed about taking birth control to reduce the chances of getting cancer as her mother once had. I instructed to increase her calcium intake because she is also at risk for osteoporosis.
Reflection
I think my interacting with this patient was what I expected it to be. She seemed like a healthy and sane young lady. I did not expect anything to be out of the ordinary. I think our whole interaction went well. The patient was cooperative. She was willing to learn and implement what needed to change. She stated, “I am open to change. I just want to be as health as possible and free of any diseases.” There were no barriers in our communication. The patient was very open minded. I was able to address exactly what she needed me to. She was very aware of things. It helped that she does have a medical background and experience in the medical field. She understood everything as it should. Our interaction with professional, clear, and pleasant. There was no misunderstanding at any point in our conversation. The patient was very open to share anything. There were no signs that the patient was withdrawing information. She was very cooperative. The patient answered every question I had for her and shared information I did not ask her to tell me. Over all, I very much enjoyed having the experience to do a health history. I find it fascinating because you get to know a person on a different level. It was a very personal experience to actually get to know what makes someone’s who they are. I have learned that people are willing to share more with you when you do not know them. I did not expect to be told so much things that I know some of my friends or family would not share with me. If I were to do this again, I would take my time and ask more about the patient’s stressors. I would make more time to ask questions about her stress because I think stress is a major thing in people’s life that effect the body and brain in so many ways.