COMPLETE HEALTH HISTORY
Laura Michelle is a 26-years old female living in Nashville. She is of Africam American descent and speaks both Spanish and English. Michelle’s marital status is currently unmarried, and she is enrolled in the nursing school program. Presently, Michelle is unemployed. She is 5.5ft tall and weighs 135lbs. Michelle is the source of this information, and she seems reliable since she can communicate clearly and she does not demonstrate any mental, physical, or communication problems that may hinder her from providing credible information.
DEVELOPMENTAL STAGE
Erickson’s stage on the basis of age: Michelle has been in an intimate relationship with her boyfriend, Andy, for the last four years, and they are planning to hold their wedding by December 2019. Apart from a recent argument that the couple had, which they successfully resolved, Michelle seems satisfied with the current state of her relationship. Michelle is not on any form type of contraceptives, and she firmly believes that her boyfriend does not have multiple sexual partners. Moreover, Michelle demonstrates a healthy relationship with her nuclear family, and they communicate several times a week via the phone. However, Michelle shows traits of disconnection from her home, although she maintains that she chose to leave home so that she could experience independence.
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Based on a close analysis of the client, Michelle is in the 6 th stage of development as stated by Eric Erikson, intimacy vs. isolation. The stage occurs in young adulthood, approximately between the ages of 18 and 40 years. During this stage, the primary conflict that individuals encounter pertains to forming loving and intimate relationships with others. According to Cherry (2017), individuals begin sharing themselves more intimately with other people and explore relationships that can probably lead to long-term commitments with people other than their family members. Successful completion of the stage often results in the sense of safety, commitment, and care within the relationships as well as happy relationships. On the other hand, the fear of relationships and commitments, as well as the avoidance of intimacy, often leads to loneliness, isolation, and in extreme cases, depression. According to Cherry (2017) success in the stage contributes to the development of the virtue of love. From this perspective, Michelle has successfully achieved the intimacy vs. isolation stage, since she has found love and an intimate partner with whom she is planning to spend the rest of her life with.
PAST HEALTH
Childhood Illnesses: Michelle notes that she did not suffer any illnesses as a child, the fact that she confirmed from her mother.
Unintentional Injuries: Michelle notes that she was a rough childhood, a factor that she attributes to the fact that she grew up around boys. Her rough nature led to her often tumbling over several times, which left her with multiple broken bones. She also underwent an elbow reconstruction surgery at the age of four.
Chronic Illnesses: Michelle notes that she suffers from recurrent pericarditis, which often gets worse during winter. She was diagnosed with the disease in 2009 by Dr. Lucia, and the doctor has been consistent in helping with the management of the condition using medication. Michelle has been hospitalized severally due to the condition.
Hospitalizations: According to Michelle, she has been hospitalized for sometimes since she was a child. At the age of 4, she was hospitalized when she was undergoing the reconstructive elbow surgery. She was also hospitalized in January 2009 following a pulmonary embolectomy. Moreover, she has been hospitalized multiple times between 2009 and 2011 due to recurrent intermittent pericarditis.
Obstetric History: She does not have a history of obstetric issues.
Immunizations: Apart from the childhood immunizations that each person is required to receive, Michelle has recently received the influenza vaccine, Hepatitis B vaccine, Varicla, Tdap, MMR, and the HPV vaccines which are all a school requirement. It is the first time that Michelle has received the influenza vaccine since childhood.
Last Examinations : The last time Michelle went for a medical examination was in January 2018, shortly before joining the nursing program. The examination comprised of cancer screenings, particularly mammogram, dental, GYN, and physical examination.
Allergies: Michelle is allergic to a number of substances, including nickel, adhesive, trazodone, and dilaudid.
Current Medications: Michelle takes alprazolam, 0.25mg, for anxiety and panic attacks. The medication also forms part of the management plan for her recurrent pericarditis.
CULTURAL ASSESSMENT
Ethnic group affiliation and racial background : Michelle was born in the U.S. to African American parents. Both her parents lived in Chicago before migrating to Nashville, where Michelle was born.
Health beliefs and practices : According to Michelle and her family, being healthy means being free from disease as well as the events or instances that cause illness. Some of the approaches through which the family ensures good health is consuming healthy diets, exercising, and getting regular medical check-ups to ensure early management of health problems to avoid complications that may be extremely detrimental to good health. Michelle being sick means that the body is not functioning as expected, therefore hindering one from comfortably performing their daily activities. She notes that illness emanates from poor diet, poor management of events that cause disease, such as environmental hazards, as well as lack of proper mechanisms, such as vaccines, to manage the emergence of diseases. Whenever Michelle is sick, she states that the first place she visits is the hospital, and she prefers going with a close person, such as her boyfriend or mother. In their family, Michelle's mother makes nearly all the healthcare decisions, including the physicians to consult, the best hospitals to visit, as well as decisions to take health insurance coverage. Michelle's mother prefers female caregivers but does not require them to share their culture ( Jarvis, 2000) necessarily.
Language barriers and communication styles : Michelle and her family are most comfortable communicating in English. Honesty is one of the elements that African Americans consider crucial in showing respect. A firm handshake and leaving sufficient personal space are other vital elements that show respect. Elements that are considered inappropriate include standing with hands on the hips, which is deemed to be rude or show of pride and same-sex touching among others.
FAMILY HEALTH HISTORY
Paternal grandfather- 82 years old, diabetic, and poor vision
Paternal grandmother- 78 years old, healthy.
Maternal grandfather and grandmother- deceased
Father- 56 years old, recently diagnosed with high blood pressure
Mother- 52 years old, healthy and alive
Brother, Andrew,- 24 years old, alive and well
Brother, Jamie- 28 years old, healthy and well
FUNCTIONAL & DAILY LIVING
Alcohol Use: Michelle admits that she occasionally takes a beer and sometimes beer whenever she goes out with her friends. She notes that her first exposure to alcohol was when she was 22 years old at a party. However, she maintains that she is not a heavy drinker and cannot go beyond four beers. She also acknowledges that she has never blacked out or driven when drunk.
Tobacco Use: Michelle has never taken tobacco in any form since she was born.
Drug Use: She has never attempted to consume any illegal drug.
Intimate Partner Violence: So far, Michelle mentions that she has only had one boyfriend and she has never experienced any form of violence from him
Travel History : She states that she loves traveling, and this year alone, she has already traveled to Greece for the New Year’s celebrations.
Work Environment/Occupational Health: Individuals working in the health sector face higher occupational health risks, particularly concerning contracting infections from patients. Hence, regarding health, Michelle takes advantage of the discounts and health screenings conducted at the institution.
Environment/Hazards:
Housing: Michelle lives in a one bedroom apartment
Neighborhood: Green Hills.
Firearms: She has no firearms in her house
Seatbelt use: Michelle always uses the seatbelt when traveling
Hobbies and Leisure Activities: Michelle loves playing basketball, reading books, and traveling.
Education/Military Service: She is currently pursuing a Baccalaureate degree and hopes to pursue her second degree when she completes the first one.
Economic/financial Status: Michelle is not employed, and therefore she does not have a regular income.
Activities of Daily Living: Presently, Michelle is capable of performing all the activities of daily living without help or support, including eating, bathing, going to the toilet, transferring, and maintaining continence.
Sleep: Michelle ensures that she gets a minimum of about 6 to 8 hours of sleep every day
Exercise: Michelle exercises for a minimum of 3 days in a week, with each session taking approximately one hour. The exercises comprise of high-intensity workouts or cardiovascular activity.
Coping and Stress Management: Some of the strategies that Michelle uses to relieve and manage stress include exercising, talking to her family to get support, and playing with her dog
Interpersonal relationships/Resources: Michelle demonstrates normal patterns when interacting with her peers.
Spiritual Resources: Michelle is a Christian, and she attends mass whenever she can. However, she is not extremely religious.
NUTRITIONAL ASSESSMENT
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Anthropometric Measurements |
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Height: __5.5ft Weight: _135____ lb Waist Circumference: __38___ inches Usual Body Weight: __135 lb___ Weight Change: plus or minus ___lbs Body Mass Index: __22.5___ kg/m2 |
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| LABORATORYDATA | |||||||||||
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Cholesterol: _____ mg/dL Triglycerides: _____ mg/dL HDL: _____ mg/dL LDL: _____ mg/dL |
Hemoglobin (Hgb): _____ g/dL Hematocrit (Hct): ____% Transferrin: _____ mg/dL TIBC: _____ mcg/dL Iron: _____ mcg/dL |
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Glucose: _____ mg/Dl HbA1c: _____ % |
Vitamin D: _____ ng/mL Vitamin B12: _____ pg/mL Folic Acid: _____ ng/mL Albumin: _____ g/dL |
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Part 1: General Diet Information |
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| Michelle does not follow a particular diet, although she tries her best to consume healthy foods. She does not have any particular food dislikes or cravings; however, she loves eating fast foods whenever she is spending time with her boyfriend. She gets sufficient financial support from her parents, which enables her to purchase foods. She is also able to prepare and store food since she owns a refrigerator. Michelle has not experienced any significant weight, diet, or appetite changes in the last year. | |||||||||||
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Part 2: Food Intake history (24-Hour Recall) |
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REVIEW OF SYSTEMS
Overall Health: Michelle exhibits a healthy posture, no signs of strain or deformity, and walks with a normal gait. She also has an excellent choice of words.
Skin: On the evaluation of Michelle’s skins, she does not have any edema, wounds, rashes, lumps, lesions. She does not have signs of varicose veins and stasis. Her skin is warm and dry. However, she has a 3-inch keloid on her chest that she has treated with an injectable steroid for the last one year with little success ( Jarvis, 2000).
Head: Michelle presents with a reasonable head shape with no abnormalities, scars, lesions, or scabs. Her hair is also healthy with no signs of vermin or scales.
Mouth and Throat: Michelle's lips are dried, and their coloration ranges from pink to red. She does not have blisters or apparent cracks in the regions. Her tongue and uvula are of the normal size. She does not have an acetone smell, and her breath is normal.
Neck: Michelle’s thyroid does not demonstrate any increased masses or obstruction of the airway. She does not have signs of enlargement of nodes.
Breast: Michelle’s breasts are relatively symmetrical in size with no reported changes in shape or size, discharge, swelling, depression, and discoloration.
Respiratory: Michelle has a history of pulmonary embolism, reporting episodes of severe pericarditis, shallow respirations, and shortness of breath accompany that during the events. The pain subsides when she is immobile and increases when she starts moving.
Cardiovascular: Michelle is always fine unless during winter when she experiences episodes of pericarditis.
Peripheral Vascular: Michelle demonstrates extremities that include 2 seconds of warm to touch capillary. Her nails are not clubbed but trimmed and clean.
Gastrointestinal: Michelle has a bowel movement once in a day, and she does not report any abnormalities concerning emptying her bowel.
Urinary: Michelle has not had any recent cases of UTIs as well issues relating with abnormal urinary discharge, excretion, pressure, or pain.
Genitalia: Michelle does not demonstrate any abnormalities with her genitalia.
Sexual Health: Michelle is intimate with her boyfriend, and she has no reported sexual health complications.
Musculoskeletal: No abnormalities.
Neurologic: Michelle does not have any neurologic complications; she can correctly follow all commands and responds to the reflex knee tap, and answer questions appropriately.
Hematologic: No abnormalities
Endocrine: No reported abnormalities or complications.
PHYSICAL EXAM
Vital Signs:
Michelle’s vitals include: temperature is 3, 7.6° C oral, 18 bpm HR: left radial pulse 80 bpm regular, and BP: right arm 120/78.
General Survey/Appearance:
1. Skin, Hair & Nails
Nails show no signs of clubbing and cyanosis. Her skin demonstrates an average temperature and texture, no lesions.
2. EENT (ears, eyes, nose, throat)
Eyes- conjunctiva is pink, and sclera is white
Ears- the external ear has no tenderness, masses, or masses, there is no obstruction in the auditory canal, while the tympanic membrane in the eardrum is translucent and gray.
Nose- no discharge, dark pink in color, and ordinary middle turbinates
Throat and mouth- no infection, bleeding, or swelling in the mucosa and gums; no lesions in the tongue; and excellent and present dentition.
3. Thorax & Lung
The thorax demonstrates symmetrical expansion during respiration, no spinal and CVA tenderness. The lungs demonstrate natural and clear resonance during percussion as well as normal and clear vesicular breath sounds during auscultation.
4. Heart and Peripheral Vasculature
No JVD was recorded at 45 0 . No bruit was noted in the carotid arteries, and a pulse was felt during palpitation.
5. Abdomen
Michelle’s abdomen is flat with no tenderness, scars, masses, bruits, and striae. Normal bowel sounds were noted, and no guarding was noted.
6. Musculoskeletal
Lymph Nodes: Neck: The submental, submandibular, suboccipital, post and preauricular, posterior and anterior cervical, and the supraclavicular are not palpable.
Axillary Lymph: The pectoral, Central Axillary, Subscapular, Epitrochlear, Superficial Inguinal, and the Lateral Axillary are not palpable.
7. Neurological
Mental Status: Michelle is alert and awake and oriented to time, place, and person; the Cranial Nerve is intact, the visual fields III and IV, oculomotor and Trochlear respectively are intact. The Nerve V (Trigeminal) is also intact, while Cranial Nerve VIII (acoustic) is equal bilaterally.
Motor System: Normal tone, 5 / 5 strength in all extremities;
Sensory:
Light Touch- normal, Position Sense- normal, Sharp- normal; Reflexes: Deep tendon: Biceps-normal, Triceps-normal, Brachioradialis-normal, Knee jerk-normal, Ankle-normal; Reflexes: Babinski reflex- none, Coordination: Gait and Balance-normal, Finger to Nose- normal, Romberg- negative.
Perceptions of health
Michelle describes health as a holistic approach that includes a psychological, mental, spiritual, and physical view of the self. Michelle’s key health goal is minimizing on stressful sessions. One of the significant health concerns that Michelle has is maintaining her current physical health and weight.
Summary
The above evaluation demonstrates that Michelle is relatively healthy despite the fact that she suffers from recurrent pericarditis. Educating the client on healthy practices would present minimal barriers since she identifies with the American culture as well as the English language. For Michelle, health education should focus on maintaining her current physical health and weight, which would necessitate engaging in more healthy eating practices and physical activities.
References
Cherry, K. (2017). Erik Erikson's Stages of Psychosocial Development. Psychology. Psychosocial Theories. Päivitetty , 14 , 2017.
Jarvis, C. (2000). Physical examination and health assessment . Philadelphia: Saunders.
