Medical Health History
Name: N/A. Gender: Female. Age: 20s. Race/Ethnicity: Caucasian/White. Occupation: Student Nurse. Education level: The patient is in the final year of her undergraduate nursing degree studies. Primary language: English. Nutrition: normal weight. Blood Pressure: Normal. Reason for visit: Annual check-up. Generally, the patient is awake, alert, and lively. The patient has no allergies to most drugs except NSAIDS, which causes her nosebleeds. Also, she has no reactions to foods and most additives. She has no signs of acute distress or any mental condition. The patient indicated she had her last annual medical check-up in January 2020. She came seeking another check-up just to make sure her health is fine and stable. Medical Health History
Perception of Health
Being a nursing student in her final year of study, the patient understands what good health is and has a positive attitude towards a healthy lifestyle. The patient understands the importance of check-ups and believes it is not good to ignore them even when generally feeling okay. The patient indicated that she follows a daily exercise routine to keep her body fit and boost her health and immunity. Although the patient is in normal weight, she has been dieting whenever she feels like her weight could be increasing. She eats three light meals on an average day and two when dieting. The patient does not use caffeinated substances, tobacco, alcohol or drugs, and avoids frequent red meat consumption. The patient stated that she uses contraceptives to prevent pregnancy since she is sexually active. However, she did not provide specific information about the contraceptives she uses. The patient demonstrated signs of eyesight complications since she frequently experiences a headache when studying in a poorly lit room.
Past Medical History
The patient indicated that she contracted chickenpox in childhood before she was immunized against the disease in the year 2000. Chickenpox is a common infection caused by the virus varicella-zoster. The infection manifests in small, fluid-filled blisters on the skin that causes an itchy sensation on the patient. The disease also causes a light cough in some patients. The itching and blister rash usually appears between 10 and 21 days of exposure through close contact with an infected person or surface. The virus lasts for five to ten days on the victim’s body. While chickenpox is considered a mild disease, it can have serious effects and complications such as pneumonia, brain inflammation, bacterial infections on the skin and bloodstream, dehydration, and sometimes death. The patient was recently immunized against influenza, hepatitis, tetanus, and MMR. The patient had no history of other medical problems diagnosed by doctors before and had never had a surgery experience. Further, the patient stated that she had no blood transfusion or previous hospitalizations in her life. The patient has been using Cryselle, a family planning drug for birth control. Medical Health History
Family Medical History
The patient is single and lives with her parents and four siblings; three sisters and a brother. She is not aware of any significant health problems with either of them. Both parents are alive in their 40s and with no health complications that she could tell. The patient has no children yet. The patient’s grandparents, both paternal and maternal, are alive in their 60s-70s. Her maternal grandfather has been suffering from COPD and CHF for the last few years. The patient is not aware of her paternal grandparents’ medical conditions and that of her maternal grandmother. The family medical history is essential in medical examination since it provides a background for evaluating any complications that may be genetic or otherwise related to the family (Bennett, 2019).
Review of Systems
Skin/hair/nails: The patient skin is white and consistent with her race/ethnicity. The skin is smooth; no lesions or bruises and has a warm temperature. Her hair has normal color and texture. The nails are pink, short, intact, normal in shape, and clean. Their capillary refill time is approximately 2 seconds. Generally, the skin, hair, and nails appear normal.
Head and neck: The patient’s head is normocephalic with no signs of injury. The skull and skin show no signs of infestation. Her face is symmetrical, without bruises, tattoos, or piercing except for a healed scar on the left side of the forehead, which she explains she knocked against the door two years ago. The neck has a symmetrical shape and indicates no signs of pulsations and masses. The lymph nodes feel and look normal with no inflammations.
Eyes, ears, nose, and mouth: The eyes are symmetrical and with no discharges. However, the patient indicates blurred vision, discomfort in the morning and at night in the left eye, difficulty with night vision, and some light headaches. The signs indicate stigmatism in the left eye. The left and right ears look normal, and the hearing also appears normal. The ears also look clean on the inside and outside. The nose is symmetrical, in the right position, and also proportional to other parts. The nose is clean and has no discharges. Her dentation looks normal, with all teeth intact and white. The lips are moist, in their right color, and the gum is well cared for. The cardiovascular, respiratory, gastrointestinal, and urinary systems appear normal with no signs of infections or any form of damage.
The patient has grown up in a stable family and has not experienced major emotional constraints. The patient has been emotionally stable over the longest part of her life, owing to both her parents’ very stable upbringing. She is in her early adulthood, and this indicates she is in the intimacy vs. isolation stage of Erickson’s eight stages of development (Jarvis, 2016). At the intimacy vs. isolation stage, the patient is concerned about establishing long-term relationships. Her physical and emotional well-being are essential, which may explain why she makes for annual medical check-ups. The patient has a positive attitude towards life, self-love, and strong self-esteem. Given that she is still in school pursuing her career, the patient has a bright future and a strong positive sense of life and healthy living.
The patient has a close connection and ties to her culture. She believes that her family is the most important social institution and defines much of what she does. The patient believes that faith is a central pillar upon which life is founded. Therefore, religion is critical in influencing her choices. The patient was born and brought up in America and has grown up among rich, educated people, which informs her health concerns and the regular check-ups. Clinical assessment such as patient observation, testing, physical examination, and recording their history is influenced by cultural factors (Gopalkrishnan, 2018).
The psychosocial assessment helps the nurse to determine if the patient is in a proper mental state or is mentally ill. The patient appears to be psychologically strong and emotionally stable. She has minimal responsibilities at home and little to care about, and hence she is fulfilled with her life. She has a strong family connection and hence social and emotional support. However, the patient has experienced stress a few times due to academics pressure and her search for a relationship identity. Generally, the patient has had no major psychological problems in her life.
The patient has lived amongst a very supportive group of people. Her parents have supported her both financially and psychologically in her academics. Besides, the parents have been her source of comfort during difficult circumstances, and in times, she needs to make complex decisions. The patient has also established a strong bond with her teachers at school, and they give her council whenever she approaches them.
The patient visited the clinic early in the morning before activities increased with the number of patients visiting. The early visit offered us an opportunity to engage at length, drawing more details from the patient and her medical files. The patient shared the information comfortably, motivated by the perceived confidentiality since we were alone in an enclosed room. The interview began with an assurance that the information shared would be handled with the utmost confidentiality. Medical Health History
With both of us being White Americans, there were no barriers in communication. We both used the English language. Besides, I gave her time to express herself with minimal interruptions. However, it was difficult for the patient to understand some of the medical terms that I used in our conversation. The success of the assignment was evidenced by the open sharing of the medical history of the patient. Generally, the assignment did not have any unanticipated challenge except the patient’s reluctance to talk at the beginning of our engagement. However, I wished I had more information on family medical treatment history, but the patient could only share that of a few members. Next time I will involve a close member of the family, preferably older than the patient. Such a member can enrich the information given by the patient and obtained from health records. The experience was different from classwork since it allowed me to the diagnostic process in healthcare from practical experience.
Bennett, R. (2019). Family Health History. Medical Clinics of North America, 103(6), 957-966. https://doi.org/10.1016/j.mcna.2019.06.002.
Jarvis, C. (2016). Physical Examination and Health Assessment. Elsevier. 7th Edition. St. Louis, Mo Medical Health History
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