please improve this job, correct mistakes and follow this instructions 

 
I have reviewed your Health History submission and would like to go over it with you so you may improve your assignment before the due date. You can edit your assignment and resubmit it before the due date. 
Under obstetrics, you want to ask your patient if they have children, how many, how were they delivered, if they suffered any miscarriages, when was their last menstrual period, are they in menopause, has she gotten a pap smear, what were the results of the pap smear. 
I noticed you were missing your genogram. Do not forget to include that. 
Under the Review of symptoms, you will use the same format as the guide provided but you would not just include “none” or only what she had. It should properly be written as ” Skin: Denies or reports rashes, lumps, sores, itching, dryness, color changes in hair or nails” if your patient suffered from something and not the other you can say ” Skin: reports rashes, lumps, sores, itching, dryness. Denies color changes in hair or nails”
According to APA, the bold titles such as “Review of systems” should be indented left and not in the middle. In your second page you should add a “Health History” (unbolded) in the center of the page and that is your title. 
Under Patterns of healthcare, you want to include if your patient actively participates in preventative care such as annuals or going to the dentist, etc. 
Remember to include identified risk factors and any health promotion activities. Also include what suggestions to made to their diet and what is their evaluation of their own diet (excellent, good, fair, poor). 
If you have any questions, please do not hesitate to contact me. 

Commentby Morgan, Dorothy Tali: Do not forget to include a running head to follow APA guidelines

Health History

Yensi Aguilar

Benjamin Leon School of nursing

NUR1060C: Adult Health Assessment

Professor Dorothy Morgan

April 7, 2021

Health History

Identifying data

Date of history: 28/02/2021

Examiner: Yensi Aguilar

Name: L.P.

Address: 3403 SW 6h Street

Phone Number: 786-

5

97-3071

Age:46

Sex: Female

Race: White

Place of Birth: Honduras

Marital Status: Married

Significant Other: Husband

Occupation: Teacher

Religion: Christian

Primary Language: Spanish

Secondary Language: English

Source of referral: The patient found the hospital’s address on the internet

Source of history: Documents with the patient’s health history gave information concerning the patient. The patient also talked concerning her health status.

Reliability: Currently, the patient seems to have a stable mental and physical state.

Chief Complaints/Reasons for Visit: According to the patient, she started experiencing high fever, blood-stained sputum, night sweats, coughing, and weight loss.

Present Illness

Time of onset: according to the patient, she started experiencing symptoms two weeks ago.

Type of onset: The patient says that she started by occasionally sweating, mild cough, headache, and pain in the abdomen area. Over time, these conditions became severe.

Original Source: The patient complains of pain in her chest and respiratory tract.

Severity: During the day, the patient does not feel many discomforts, but it becomes worse at night due to lower temperatures. Hence, the condition does not deter the patient from executing tasks during the day. The severity of her state is at 5 out of 10 on a 0-to-10-point scale.

Radiation: At night, the patient feels severe pain throughout her chest region

Time Relationship: At first, this condition was still developing and was easy to handle. However, it has evolved and has gotten worse.

Duration: It has been two weeks since the patient started experiencing the symptoms.

Association: The symptoms experienced by the patient are similar to those of flu.

Source of Relief: According to the patient, she feels better when resting after doing some light physical exercise.

Source of Aggravation: The symptoms become worse during the night. Again, exposure to allergens such as dust or cold increases the symptom’s severity.

Past History

General State of Health: The patient’s general condition is fair, considering she is suffering from a chronic illness.

Childhood Illnesses: She suffered from smallpox and measles as a child

Adult Illnesses: Hypertension, Anemia, and asthma

Psychiatric Illnesses: She has experienced mild depression in the past

Accidents and Injuries: Never had an accident or injuries

Operations: The patient denies any surgical operations

Hospitalizations: After visiting the hospital, the patient got an admission to the Jackson Hospital for one week to undergo treatment for asthma and hypertension. She received treatment and later discharged after the end of the 7th day. Healthcare providers advised her to quit smoking and taking alcoholic beverages.

Obstetric:

Do you have children? Yes

How many children do you have? Two

How did you deliver them? Natural delivery

Have you ever had a miscarriage? No miscarriages

When was your last menstrual period? 2 weeks ago

Are you in menopause? No

Have you had any recent pap smears? Yes, six months ago

What results did the pap smear give? Cancerous cells present

Family Genogram

5

Current Health Status

Current medication: the patient is currently taking hypertension and flu antibiotics medication such as azithromycin and acetaminophen. Comment by Morgan, Dorothy Tali: Put the specific medication with dosage, how many times a day, and route.

Allergies: the patient is allergic to fur and dust particles Comment by Morgan, Dorothy Tali: Include what reaction they get to the allergies

Screening tests: she has undergone throat and lung cancer screening Comment by Morgan, Dorothy Tali: Be specific. What tests did she complete, when, and what were the results

Immunizations: vaccines are up to date including influenzae

Family History

Maternal/Paternal Grandparents: both died from a natural illness Comment by Morgan, Dorothy Tali: What is natural illness mean? Be specific

Parents: Mother is 55 years old, diagnosed with Diabetes and hypertension. Her father died from cancer at age 62. At age 30, her father had a diagnosis with a mental disorder.

Aunts/Uncles: paternal uncles died from HTN. Paternal aunts are alive but diagnosed with mental disorders.

Siblings: 1 brother and three sisters Comment by Morgan, Dorothy Tali: Are the siblings healthy?

Spouses: Husband is alive and is a 48-year-old healthy man

Children: 2 children, one boy, and one girl Comment by Morgan, Dorothy Tali: Are the children healthy?

Review of Systems Comment by Morgan, Dorothy Tali: You are not writing an assessment. Your review of systems should only say “Patient reports…” or “Patient denies..” then answer to each body system pertaining using the example of the Health History on Blackboard.
Review of systems
General: Overall state of health, changes in ADL’s, weight, fatigue, fever, increased infections.
Skin: Rashes, lumps, sores, itching, dryness, color change changes in hair or nails. NEUROLOGIC: Seizures, headaches, paralysis. Numbness, weakness, syncope, restless, tremors, blackouts.
Eyes: Vision, glasses, contacts, ? Last eye exam, pain, redness, excessive tearing, double vision, blurred vision, glaucoma, cataracts.
Ears: Hearing, tinnitus, vertigo, earaches, infections, discharge ? Hearing aids.
Nose and Sinuses: Frequent colds, nasal stuffing, discharge, hay fever.
Mouth and throat: Condition of gums and teeth, dentures, last exam, dry mouth, frequent sore throats hoarseness.
Neck: Lumps, “swollen glands”, goiter, pain, stiffness.
Breast: Lumps, pain, nipple discharge? Self-exam.
Respiratory: Dyspnea, SOB, pain, wheezing, crackles, orthopnea, (?) Pillows, cough, sputum (color, quantity), emphysema, bronchitis, asthma, URI, chest x-ray.
HEALTH HISTORY 7
Cardiac: Heart trouble, high blood pressure, rheumatic heart fever, murmurs, palpitations, chest pain, dyspnea. paroxysmal nocturnal dyspnea, edema, EKG, other heart test results. Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, vomiting. Frequency of bowel movements, change in pattern, rectal bleeding or black tarry stools, hemorrhoids, constipation. diarrhea. Abdominal pain, food intolerance, excessive belching or passing gas. Jaundice, liver or gallbladder trouble, hepatitis.
Urinary: Frequency, polyuria, nocturia, burning or pain on urination, hematuria, urgency, hesitancy, dribbling, UTI’s, stones.
Genital:
Male: Hernia, discharge, testicular pain or masses, history of STD’s and treatments, Sexual preference, interest, satisfaction, and problems.
Female: Age of menarche; regularity, frequency, and duration, amount of bleeding.bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension, age of menopause, menopausal symptoms, post- menopausal bleeding. If born before 1971, exposed to DES from maternal use. Discharge, itching, sores, lumps, STD’s and treatment. Number of pregnancies, deliveries, abortions, complications of pregnancy, birth control methods. Sexual preference, interest, function, satisfaction.
Peripheral vascular: Intermittent claudication, leg cramps, varicose veins, past clots. Musculoskeletal: Muscle or joint pains, stiffness, arthritis, gout, backache. Hematologic: Anemia, easy bruising or bleeding, past transfusions and any reaction. Endocrine: Thyroid trouble, heat or cold intolerance, excessive sweating, diabetes, excessive thirst or hunger, polyuria.
Psychiatric: Nervousness, tension, moods, depression, memory

General: High fever, night sweat, coughing

Skin: Reports warm, dry, and intact good turgor. Denies sores, rashes, lumps, unusual bruising, and edema

Neurologic: No seizures or memory disorder

Head: Generally round, with prominence in the frontal and occipital area (Normocephalic Comment by Morgan, Dorothy Tali: Remember you are not charting an assessment. Be sure to fix all the ones who describe an assessment

), depressions, atraumatic, no palpable masses, and scaring. However, the patient complains of dizziness but denies pain.

Eyes: Denies light sensitivity, clear conjunctiva, intact visual acuity, sclera non- icteric, PERRLA, and EOM (six cardinal gazes). No diplopia is present.

Ears: the patient denies tinnitus, sensitivity, or pain, no otorrhea present. The whisper test is standard.

Nose and Sinuses: clear nares and mucosa non-inflamed septum. No external lesions, congestion, epistaxis, or erythema present.

Mouth: Moist mucous membrane without mucosal lesions.

Gums/Teeth: full Bridge present.

Throat: No pain in swallowing nor dysphagia present.

Neck: No Stiffness and swollen glands

Breast: Normal

Respiratory: Cough and shortness of breath.

Cardiac: frequent chest pain

Gastrointestinal: Normal peristalsis, denies pain and no jaundice. Normal Tympanic sounds no hyperactive or hypoactive sounds present,

Genitourinary: the patient denies dysuria, hematuria, and nocturia frequency. She also has standard urine color, and no bleeding is present.

Genital: Female: Normal menstrual cycle

Peripheral Vascular: No vascular swellings

Musculoskeletal: Mild stage of arthritis in the right knee. The patient also complains of pain in the sacral area from past injury.

Hematologic/ lymphatic: Denies bleeding, bruising, or enlarged cervical, clavicular lymph nodes.

Neurologic: Cranial II-VII are intact; 2+, good reflexes, intact to touch, pinch and vibrations. Romberg and pronator test passed accurately.

Endocrine: the patient has polyuria, polydipsia, polyphagia, and heat and cold intolerance.

Psychiatric: the patient has depression, mental disturbance, suicidal ideas, paranoia, anxiety, and tension because of her stressful job.

Functional Assessment (Including Daily Living Activities)

Financial Status-Stable

Value-belief system- Christianity

Self-care activities – Balanced diet and regular exercises

High Self-Esteem and Self-Concept

Exercises: Morning runs

Leisure activities: Watching movies

Exercise pattern- 3 times a week

Other self-care behaviors: reduction of alcohol intake
Sleep/Rest: 8 hours of sleep daily

Nutrition/Elimination: increased carbohydrate intake

Is this menu arrangement typical of many days? -yes

Who buys meals? – the patient does it herself

Who cooks the food? – she prepares her food

Are finances enough for food? -Yes

Who is available during mealtimes? The patient and her husband

Other self-care behaviors- keeping warm at all times

Interpersonal resources/relationships

The patient’s role in the family: As a married woman, she works to contribute financially.

How does she get along with her family, friends, coworkers, and classmates? She has a good relationship with them all.

Where does she support her problem? From her husband and workmates

How much daily time does she spend alone? After work until the following morning

Is it pleasurable or isolating? – Pleasurable since she likes spending some time alone

Other self-care behaviors- Interacting with colleagues and friends to avoid loneliness

Describe stress in life now- Her diagnosis increases her stress level

Change in the past year- she was not stressed before diagnosis

Methods used to relieve stress- Interact with people and visit a psychiatrist

Are these techniques practical? – yes

Personal Habits including Daily caffeine intake such as coffee, tea, or colas

Smoking cigarettes- frequent smoker

Packet numbers per day- 1

For how long? – 12 years/daily

Age started- 23

Any prior attempt to quit smoking? What was the experience? She relapsed after two months.

Alcohol intake – On weekends.

Last date to consume alcohol – Last Saturday

Alcohol quantity taken during that episode- 3-4 wine cups

Number of days she took alcohol within the last 30 days- 3

Ever had a drinking challenge? No

Any street drug use? None

Environment/Hazards

Neighborhood and housing: Middle-class neighborhood

Area safety? Safe

Enough utilities and heat? Easy access to amenities

Involvement in community services: Weekly cleaning exercise in the neighborhood

Home or workplace hazards: N/A

Seatbelts use: Always

Residence or travel in other nations: No

Military amenity in other states: N/A

Self-care deeds: Always putting on a seatbelt while traveling from place to place

Occupational Health

Jobs held: Teacher

Satisfaction with present and past employment: Satisfied with salary and work conditions

Current place of employment: Teachers Service Commission

Please describe your job: Teaching high school students

Have you worked with any health risks? N/A

Is there equipment designed to reduce your exposure at work? N/A

Are there programs designed to observe your direction? N/A

Are there health risks that you think may relate to your job? N/A

What do you dislike or like about your profession? It pays well and has a friendly environment. Though the job is too demanding and stressful sometimes, the patient can handle it.

Perception of own health

View of own health now: Treatable

Reaction to illness: Stressed and depressed

Coping patterns/mechanisms: Taking prescribed medication

Value of health: Among the topmost life priorities

What are your worries: To quit smoking.

What are your expectations concerning your future health? To heal and get back to everyday life.

Your health goals: Improve my health by taking a balanced diet and avoiding drugs

Educational level

Grade level or highest degree attained: A Bachelor’s Degree in Education (Science)

Intellect judgment based on age Comment by Morgan, Dorothy Tali: Fill this out. You want to explain what their opinion of intellect is in regard to their age. So their own views. 

Patterns of health care

Dental care: the patient visits the dentist regularly for cleaning and cavity prevention.

Preventive care: Frequent visit to the general doctor and OBGYN for annual pap smears and mammograms. Comment by Morgan, Dorothy Tali: Include time frame. When do you do their preventative care and how often?

Emergency care: Medical emergency number on patient’s speed dial.

Disease risk factors: the patient’s family history, alcohol consumption, cigarette smoking, and age increases her chances of illness.

Health promotion activities: the patient should participate in regular physical activities, maintain a fit body weight, and avoid stress and smoking. Additionally, the patient should consider changing her eating habits as the most significant health promotion strategy. Comment by Morgan, Dorothy Tali: You are missing the developmental data.
Developmental data:
Summary of developmental data and current functioning. Use Erikson’s stages of development.
Under the Eriksons stage you want to decide what stage your patient is in and write about it

NUTRITIONAL ASSESSMENT

6

17

Client’s Height _______5.9 feet________

Weight _______204.7 pounds_______________

Projected Calories:

Daily intake 2000 calories

Recommended weight

197.5 pounds

24-Hour Diet Recall;

TIME

FOOD EATEN

CALORIE AMOUNT

BREAKFAST

1 cup of Semi-skimmed milk
one mug of instant powdered coffee
Homemade date cake

42
10
66

LUNCH

Homemade steak pie served with boiled potatoes and French beans.
Orange squash

520
1.7

DINNER

Salad (Lettuce, tomatoes, beetroot, and grated cheese)
Fried fish served with vegetable rice

125
376

SNACK

one large fruit dish of sliced bananas, pineapples, watermelon, and pawpaw
one glass of water
White bread with butter

50
0
200
353

EVALUATION

FOOD CATEGORIES

SERVINGS NEEDED

SERVINGS EATEN

EVALUATION

Animal Protein

2

3

Excellent

Vegetable Protein

2

0

Poor

Dairy products calcium-rich

4

3

Fair

Whole grains, bread, and cereals

4

5

Excellent

Vitamin c-rich foods

1-2

1-2

Good

Green. Leafy vegetables

1-2

3-4

Excellent

Other fruits and vegetables

2

4

Excellent

Fats and oils

2

2

Good

Other foods

1

1

Good

Comments:

Diet Suggestions:

Increase calories _____2500______ Decrease fat ________15g______

Decrease sugar ______25g______ Increase fiber ________30g______

Increase number of meals ______3 meals____ Other _Vitamins and minerals _________

Referred to food programs

References

Jarvis, C. (2015). Physical examination and health assessment. Elsevier Health Sciences.

O’Brien, S. M., Lamanna, N., Kipps, T. J., Flinn, I., Zelenetz, A. D., Burger, J. A., … & Johnson, D. M. (2015). A phase 2 study of idelalisib plus rituximab in treatment-naive older patients with chronic lymphocytic leukemia. Blood, bslood-2015.