Nursing 6830 Comprehensive Adult Health History

Nursing 6830 Comprehensive Adult Health History

Otterbein University Graduate Studies in Nursing

Nursing 6830 –Spring 2021

Appendix C

Comprehensive Adult Health History

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  1. PROBLEM LIST

Active Problems are as follows

  1. Asthma
  2. Type 2 Diabetes Mellitus
  3. Polycystic Ovarian Syndrome (PCOS)-Patient had menstrual abnormalities before initiation of birth control pills, has facial hair on upper lip and acanthosis nigricans on the neck. Clinical features of PCOS include hirsutism, acanthosis nigricans, menstrual abnormalities, obesity and subfertility (Rasquin-Leon & Mayrin, 2020).
  4. Allergic conjunctivitis-evidenced by itchy and red eyes on exposure to allergens
  5. Acne-evidenced by scattered pimples and pustules on the face

Inactive Problems

  1. Anxiety
  2. Sleep problems

Risk Factors

  1. Family history of hypertension, diabetes mellitus, colon cancer, and dyslipidemias. Genetics factors and hereditary component are implicated as risk factors of majority of cancers, hypertension and diabetes mellitus (Johnston et al., 2019)
  2. Allergens-Cats, house dust mites and Penicillin drug
  3. Heavy duties such as climbing the stairs exacerbates her asthma. Nursing 6830 Comprehensive Adult Health History

 

  1. COMPREHENSIVE HISTORY (Subjective Data)

Date: 2/02/2021

Initials: TJ

Age: 28

Sex: Female

Ethnicity: African American

Marital Status: Single

Occupation: Accounting Clerk

Source of Data: The patient

Reliability: Ms. TJ communicates with confidence, relays information openly and without hesitation. She is clear, coherent and straight to the point. She is calm and collected throughout the interview, and maintains eye contact.

Chief complaint(s) /presenting problem

“I have come for a pre-employment medical check-up to secure a health insurance cover at my new job place:

History of Presenting Illness

            Ms. TJ has recently secured an employment at Smith, Stevens, Stewart & Silver Company where she is supposed to work as an Accounting Clerk. As per the job requirements, she is supposed to have a complete physical examination for health insurance at her work place. She presents to the clinic with no acute current medical complaints, other than the need for a medical check-up. She is a known diabetic patient since 24-years of age. 5-months ago while on another medical check-up, the nurse prescribed her Metformin. Even though she reports no current side effects of the drug, she confirms flatulence was the major initial side effect. Further, she reports to maintain a stable blood glucose using the drug, diet and exercise. 4-months ago, she visited Shadow General Health Clinic for her annual gynecologic examination. Her doctor diagnosed her with PCOS and prescribed her birth control pills. Since the prescription, she reports good response and able to see her periods monthly.

She reports being happy about her new job and wishes to advance her carrier with the company. Currently, she has good control of her health as compared to few years ago. Further, she reports having no stressful life events. She reports having close friends and attending the church has helped her cope with stress and is the reason for her healthy living. Further she attributes the dissipation of her anxiety and sleep problems to her good social network.

Medications

  1. Metformin 850mg, PO, BD. She took the last dose this morning- For her diabetes
  2. Proventil/Albuterol 90 mcg/spray Metered-dose inhaler (MDI) 2 puffs every 4 hours prn. The last dose was taken (last use was three months ago; and twice in the last year)-For her asthma
  3. Flovent daily inhaled PO, BD (the last use was early this morning)-For her asthma
  4. Fluticasone propionate, 110 mcg 2 puffs twice a day (the last use was this morning)
  5. Yaz/ Drospirenone + ethinyl estradiol PO; takes every morning with meal (the last use was this morning)-For PCOS
  6. Advil/Ibuprofen 600 mg PO TID prn-For her menstrual cramps. She used the drug last 6-weeks ago
  7. Acetaminophen 500-1000 mg per oral when necessary (prn) for her headaches

Denies use of any herbal medication, or over the counter vitamin supplements.

Allergies: Allergic to cats, house dust mites and Penicillin. On exposure to the allergens, she has dyspnea, runny nose, itchy eyes, swollen and red eyes. Her asthma symptoms and allergic conjunctivitis symptoms worsens. She gets Penicillin rashes on use of the drug. Not allergic to food and latex. She reports no seasonal allergen.

Seasonal allergens occur only during specific periods of a year while perennial allergens such as house dust mites exist throughout the year (Dhingra & Dhingra, 2017)

 

Tobacco Use: No history of tobacco smoke

Alcohol and Drug Use: No history of alcohol consumption, no cocaine. She smoked pot but stopped 7-8 years ago while she was 20-21 years of age.

Past Medical History

            Childhood Illnesses: She was diagnosed with asthma at 2 ½ years of age. She uses Flovent as a daily inhaler and Albuterol as a rescue inhaler: She experienced several asthma attacks while young and recently, had an attack three months ago which resolved on using an inhaler. The last time she was admitted of asthma was in high school. She also has allergic conjunctivitis which presents as itchy and red eyes on exposure to allergens. She prevents the allergic reactions through avoidance of the allergens. According to Campo et al (2019), allergen avoidance is the initial step to avoid the sequela of allergic reactions.

Adult Illnesses:

Medical: She was diagnosed with Type 2 DM at 24 and put on Metformin 850mg PO BD 5-months ago. She reports to experience flatulence as a side effect of the drug which has since dissipated. She reports to use probiotic yogurt to exonerate flatulence. She reports a regular blood glucose monitoring every once daily. The readings as reported are usually about 90 mg/dl. The normal serum glucose levels in an adult range between 74 and 106 mg/dl (Patolia, 2019 Nursing 6830 Comprehensive Adult Health History). She was also diagnosed with hypertension which she manages by exercise and diet.

Surgical: No significant surgical history

OBS/GYN: Her menarche was at 11years and sexual debut at 18 years of age. She is straight/heterosexual and has sex with men. She reports to have a new boyfriend with who she has not initiated sex with. However, she plans to use condoms as a contraceptive method on initiation of sex. She has never been pregnant. Her last menstrual period (L.M.P) was two weeks ago. On her last annual gynecologic examination, 4-months ago, she was diagnosed with PCOS and put on Yaz. Since then, her cycles have been regular every four weeks. She reports minimal bleeding which lasts for five days. During the same annual examination, she was tested of HIV/AIDS and other STIs which turned out negative.

Psychiatric: No history of mental disorders.

Health Maintenance: All her immunizations are intact

Screening Tests: Pap smear done four months ago. No abnormality detected.

Family History

            She is the first born in a family of three children. The mother is alive while the father is deceased. The mother is 50-years of age and has hypertension and hypercholesterolemia. The father had hypertension, diabetes and hypercholesterolemia. Her brother is 27, and is leading a healthy life. The younger sister is also asthmatic; however, she rarely experience attacks. The maternal grandmother died 5-years ago while she was 73. She died of stroke, and had other comorbidities including hypertension and hypercholesterolemia. Maternal grandfather is also deceased and died of a heart attack. Likewise, he had hypertension and hypercholesterolemia. The paternal grandmother is 82 and is alive. She is hypertensive and on anti-hypertensive medications. She also has hypercholesterolemia. The paternal grandfather died of colon cancer. He had other comorbidities including hypertension and diabetes. In summary, there is family history of diabetes mellitus, hypertension, colon cancer and hypercholesterolemia.

Personal and Social History

She is an Accounting Clerk and has secured a new job which she is to report in two weeks’ time. She is happy about her new job and hopes that it would be an enticing endeavor for her. She wishes to advance her carrier with the company, obtain promotion in few years and to achieve the highest possible ranking. She reports having a supportive family which she describes as a tight knit, and reports a good relationship with her siblings. She has retained few friends from high school and has formed new friends from the church. The relationship among them is cordial. Her family has a staunch Christian background and attends the First Baptist Church. After the church sessions, she socializes with her friends. She reports to attend Bible Studies on Wednesdays. She reports being stressed initially which she has coped with. Interacting with friends and attending the church has significantly helped her cope with stress. Further, she had sleep problems which have resolved following the good social support. She sleeps for circa, 8-9 hours per day. She is on a diabetic diet which, in addition to exercise and medication, uses to manage her diabetes. She reports no alternative healthcare practices such as herbal medications.

Review of Systems:

General: Denies fever, chills, fatigue and body weakness. She reports feeling heavy lately (BMI of 29).

Skin: Reports having zits on the face and hirsutism on upper lip. She reports darkening of the skin around the neck. She reports no hair or nail changes. No rashes, itchy or dry skin. No tingling sensations on the skin. Lumps on the face consistent with acne

Head: She denies history of head injury, altered mentation or dizziness. She reports occasional headaches. No lightheadedness.

Eye: No visual changes, uses glasses. Last eye check-up revealed no problem. She denies eye pain, diplopia and blurry vision. She reports itchy and red eyes on exposure to cats and house dust mites. No glaucoma or cataracts.

Ears: No hearing loss, discharge or pain. No crusting, tinnitus and vertigo. She denies use of hearing aid. No previous or current ear infections

Nose: Denies discharge, nasal congestion and stuffiness. She denies nasal bleeds, itching or frequent colds. She denies sinus tenderness. No hay fever or any other nasal trouble.

Throat: Good sense of taste, no xerostomia and mouth pain. She denies voice changes and sore throat. She denies bleeding gums, dental caries, halitosis or tooth ache. She denies problems with the tongue. Denies use of dentures or any dental prosthesis

Neck: Denies any deformity, masses or swellings. No neck stiffness or pain

Breasts: She denies breast pain, discharge, masses, ulceration, or axillary masses.

Respiratory: Denies cough, sputum and hemoptysis. She reports difficulty in breathing, wheezing and chest tightness on exposure to the allergen and on doing heavy activities such as climbing the stairs.

Cardiac: She is hypertensive. She denies palpitations, chest pain, orthopnea, paroxysmal nocturnal orthopnea. No previous ECG findings

GI: She denies nausea, vomiting, diarrhea, constipation, abdominal pain, bowel habit changes and flatulence. However, she reports having experienced flatulence initially which has dissipated. Has no food intolerance.

Peripheral Vascular: Denies intermittent claudication or swelling of the calves, legs or feet. No previous history of DVT. No color changes in the toes or fingertips during cold.

Urinary: Denies increased frequency of urination, nocturia, polyuria or urgency. She denies burning sensation or dysuria. No hematuria, flank pain, urinary infections or incontinence.

Genital Female: Age at menarche-11; regular menstrual cycle, after every 4-week, lasts for 5-days with minimal bleeding. No inter-menstrual or post-coital bleeding. LMP at 2-weeks ago, last dysmenorrhea experienced 6-weeks ago. She reports a whitish vaginal discharge, non-foul smelling and no itchiness. No STIs, sores or vaginal lumps. No obstetric history. Heterosexual and have sex with males; sexually active even though hasn’t initiated sex with new boyfriend, uses condoms. No satisfaction problems or dyspareunia. Previous HIV/AIDS testing revealed negative.

Musculoskeletal: Denies joint pain or stiffness. She denies joint pain with systemic features such as such as fever, rash, chills, rash, weakness, anorexia and weight loss.

Psychiatric: She is conscious, well kempt, friendly to the interviewer, calm and collected. She has good mood and affect. No depression or anxiety. No memory loss, suicidal thoughts or acts.

Neurologic: GCS of 15. She is oriented to time, person and place. She has a clear and coherent speech. Memory is intact. Insight, abstract and judgment are good. Reports occasional headaches which she manages using Acetaminophen. No history of fainting, vertigo, dizziness or black outs. No numbness or tingling sensations, no paralysis and tremors.

Hematologic: Denies bleeding diathesis, previous blood transfusions and transfusion reactions. No anemia

Endocrine: No polyuria, polydipsia or polyphagia (DM well managed). She denies heat or cold intolerance. Denies increased diaphoresi

References for Nursing 6830 Comprehensive Adult Health History

Campo, P., Eguiluz-Gracia, I., Plaza-Serón, M. C., Salas, M., José Rodríguez, M., Pérez-Sánchez, N., González, M., Molina, A., Mayorga, C., Torres, M. J., & Rondón, C. (2019). Bronchial asthma triggered by house dust mites in patients with local allergic rhinitis. Allergy, 74(8), 1502–1510. https://doi.org/10.1111/all.13775

Dhingra, P. L., & Dhingra, S. (2017). Diseases of ear, nose and throat-eBook (7th ed.). Retrieved from https://play.google.com/store/books/details?id=JfHQDwAAQBAJ

Johnston, M. C., Crilly, M., Black, C., Prescott, G. J., & Mercer, S. W. (2019). Defining and measuring multimorbidity: a systematic review of systematic reviews. European Journal of Public Health, 29(1), 182–189. https://doi.org/10.1093/eurpub/cky098

Patolia, S. K. (2019). Glucose. Retrieved February 3, 2021, from Medscape.com website: https://emedicine.medscape.com/article/2087913-overview

Rasquin Leon, L. I., & Mayrin, J. V. (2020). Polycystic Ovarian Disease. In StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459251/#_NBK459251_pubdet

Appendix