Health History Needs Assessment

Subjective Data 

The subject under consideration and discussion is a 40-year old female who receives an average income since her highest level of education is high school. Besides, she is married and is a part-time teacher affiliated with the Christian faith. The 40-year old has four children and is registered with a health insurance company as required by the PPACA. The reason for care is a resurgence of high blood sugar caused by her diabetic condition. Indeed, she has been struggling with diabetes mellitus (Type II) from 2014. Her general health does not seem good since she experiences long spells of tiredness and dizziness. She has also reported occasional spells of passing out and poor coordination with a persistent headache.

Since her diagnosis, she has been injecting herself with prescribed Liraglutide twice a day. Other medications include those for comorbid conditions such as high blood pressure and pain relievers for the headaches. She has no allergies, and the only vaccinations in her file are childhood vaccinations she was administered for polio and measles. Two cases of diabetes have been observed in her family history. The first case is her great grandfather who was diagnosed with Type I diabetes and the second case is her mother who was diagnosed with Type II diabetes. No other siblings or relatives have been diagnosed with any form of diabetes. Most of her body systems seem to be functioning normally other than eyesight and the CNS, which explains her passing out. In terms of developmental considerations, her cognitive ability has been affected due to the exacerbation of the condition, which has starved the brain of sufficient energy for coordination.

Her cultural view and belief regarding the disease are that it is unnatural and that there is more than what meets the eye regarding supernatural factors resulting in the contraction of the condition. As a black woman, she believes such diseases are prevalent in the white community who indulge in a ravenous lifestyle. Nonetheless, her assertions are cultural stereotypes, since overweight Blacks have a prevalence rate of 60% as opposed to 33.3% in whites (Zhang, Wang, & Huang, 2009). Regarding psychosocial considerations, the subject has become depressed and conserved; phenomena worsened by the cultural stereotypes of her community. Besides, the frequent urination and passing out have significantly lowered her self-esteem seeing that she is far from normal compared to other people.

Objective Data 

HEENT 

The HEENT exam showed that the subject has minor head injuries due to occasional passing out with no brain trauma. Her eyes also demonstrated signs of developed cataracts, which explain the blurred vision. Nonetheless, her ears and nose showed good health. Her throat, however, showed signs of desiccation due to the frequent feeling of thirst.

Neck 

The exam pertinent to this region, especially the thyroid region has evidenced mild lumps of cells indicating an early onset of thyroid cancer. Nauck & Friedrich (2013) ascertain that the long term use of Liraglutide is associated with the development of thyroid cancer.

Respiratory System 

Despite the frequent thirst and dry throat, the respiratory system seems to be functioning normally.

Cardiovascular System 

The cardiovascular system seems to be functioning properly. As such, there is no serious cause for concern other than the increased heartbeat rate that is caused by the lack of energy in the body, which results in weakness and spells of dizziness and passing out.

Neurological System 

Examination and tests on the above system evidenced mild-moderate effects that explain the loss of coordination and deteriorating cognitive functioning.

Gastrointestinal System 

Examination of the system showed signs of hyperglycemia and gastroparesis, which in turn result in nausea and vomiting.

Musculoskeletal System 

Because of the worsening of the condition whereby the muscles do not gain sufficient energy and possible resistance to the prescribed drugs, the above system has been compromised thus exhibiting symptoms such as muscle tremors and trembling.

Peripheral Vascular System 

On examination, the above system seems to be functioning normally.

Given the physical examination and health history of the patient, an emerging fundamental health education topic for the subject is healthy habits, which not only refer to indulging in healthy eating but also exercising. Therefore, reducing fat consumption and increasing vitamin and protein consumption such as fruits and vegetables and lean meat is pivotal to the subject’s health. Also, indulging in physical exercises including aerobics will lower the subjects blood sugar levels, lower the blood pressure, improve memory, and reduce dizzy spells and passing out by improving blood flow (NIDDK, 2016).

The second health education need is knowledge regarding the correlation between racial or ethnic disparities and the prevalence of diabetes. Indeed, the subject harbors unfounded cultural beliefs and stereotypes regarding her ethnicity and the prevalence of the condition. With proper education under the above mentioned educational topic, her assertions will be debunked thus creating a new understanding regarding the risk factors such as family history and how they relate with contraction of the condition.

In this regard, the two selected journal articles for the topics and needs discussed above are

Sergeant, C., & Dyson, P. A. (2018). Diabetes and Diet: A Patient and Dietitian's Perspective.  Diabetes therapy: research, treatment, and education of diabetes and related disorders ,  9 (5), 1733-1739. Doi:  10.1007/s13300-018-0500-7 

Zhang, Q., Wang, Y., & Huang, E. S. (2009). Changes in racial/ethnic disparities in the prevalence of Type 2 diabetes by obesity level among US adults.  Ethnicity & health ,  14 (5), 439-457. Doi: 10.1080/13557850802699155

Reflection 

The assignment has fulfilled and met all my expectations regarding course material and its application in real-life scenarios. The course has taught me how to interpret historical information and how medical and family history act as risk factors in contracting certain health conditions. Nonetheless, the major communication challenge was explaining to the subject how family medical history and genetics are the major factors in the development of the condition. This challenge can be overcome through proper education and awareness creation of the patient regarding risk factors, especially under the two topics identified above.

The main unanticipated challenge of the assignment was conducting the tests and recording results. However, the advantage is that the exercise has enabled me to gain positive experience, knowledge, and insight into how medical conditions and diseases affect the different body systems and how the corruption of one system affects the functioning of another. The lacking information that I desired in the completion of the assignment was the specificity of what aspects of developmental considerations were required such as physical, social, psychological, or cognitive.

For the next project, I will write down specific, measurable variables that I would like to investigate based on the condition. Also, I will research the condition presented by the subject regarding its pathophysiology and affected organs and systems and therefore ease the physical examination process.

References

Nauck, M. A., & Friedrich, N. (2013). Do GLP-1–based therapies increase cancer risk?.  Diabetes Care ,  36 (Supplement 2), S245-S252. https://doi.org/10.2337/dcS13-2004

NIDDK. (2016). Diabetes diet, eating, & physical activity. NIH. Retrieved from https://www.niddk.nih.gov/health-information/diabetes/overview/diet-eating-physical-activity

Zhang, Q., Wang, Y., & Huang, E. S. (2009). Changes in racial/ethnic disparities in the prevalence of Type 2 diabetes by obesity level among US adults.  Ethnicity & health ,  14 (5), 439-457. Doi: 10.1080/13557850802699155.